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introduction social media enable modes of professional selfpresentation that were previously impossible by carefully constructing social media profiles and posts otherwise invisible information can be shared such material can include posts about an individuals expertise the extent of their social networks and their association with specific projects which can help make them more noticeable and facilitate new opportunities with these end goals in mind individuals give extensive thought to what they share in order to ensure that the inferences fostered via social media are favourable the cumulative impression created by profiles and posts can be used in a variety of ways to make judgements that can have significant implications for their career trajectories the growing attention employers give to casual posts from personal profiles has caused some uneasiness increasingly the content of informal posts is used alongside professional information to form inferences about a person and their capabilities judgements can be informed by personal profiles posts about out of work activities and information or pictures posted by other people the ubiquity of the internet and the interconnectedness of social media networks mean that professional and social boundaries are blurred resulting in a spill over of information from one life domain to another as information seeps across digital networks it becomes more difficult to control impressions cultivated by social media the negative inferences associated with contextually inappropriate personal posts can have serious consequences for individuals and organisations for instance justine sacco became infamous for a distasteful joke on her personal twitter account posted as she boarded a plane for a holiday in south africa by the time her plane landed eleven hours later her tweet had gone viral and her employer had fired her although her tweet was not directly connected to her professional persona it was used to infer that she was racist which was at odds with her role in a public relations firm despite these challenges the availability of additional sources of personal information can also be seen as an impression management opportunity one possible reason for the inclusion of personal information in a professional social media footprint is that it enables people to be more creative about how they communicate their work identities helping them to differentiate themselves and stand out these more relaxed sources are difficult to manage since they can include other peoples posts which have the potential to undermine professional impressions recent social media studies focus on how individuals attempt to separate personal and professional social media interactions this paper complements such studies by exploring how professionals imply positive personal characteristics by using multiple professional and personal social media sources in concert our findings show that while individuals are keen to achieve a competitive edge with their creative use of social media profiles they are also alert to the potential impression management problems this could create while disrupting the boundaries between their personal and professional accounts can be challenging they cope by establishing liminal transitionary states of mind that help them to take stock of what they can appropriately disclose to their professional colleagues we contribute to the social media literature by conceptualising this kind of selfpresentation as a type of postmodern selfperformance the rest of the paper is organised as follows first we review the literature on the opportunities and challenges of social media use for professional selfpresentations in particular we draw attention to the prevalent assumption that individuals prefer to separate their different life domains on social media we argue that in some instances individuals also use social media to disrupt traditional domain boundaries the second section of the literature review draws on sociological theory and offers a theoretical overview of how people communicate in a way that fosters inferences in the minds of others in the methods section we explain our research design and method of data analysis the subsequent findings section describes the experiences of the participants as they used social media to reveal aspects of their lives that would not traditionally be on display in an organizational setting in the discussion section we elaborate upon the implications of such behaviour comparing the hybrid selfpresentations to postmodern theatrical performances designed to engage an audience in new and meaningful ways the theoretical and practical implications of the increased willingness to selfdisclose on social media are discussed 2 professional selfpresentations on social media social media are increasingly being used by individuals to create positive professional impressions this process is initiated as profiles are made visible to work colleagues and professional connections enabling them to traverse a variety of different personal information social media footprints are not limited to a single account and often comprise information distributed across a number of different sites colleagues may simultaneously be connected on linkedin and facebook view each others tweets and blog posts and be part of a bespoke organisational wiki or network each source of information helps make inferences about the attributes and characteristics of a person in a professional setting such inferences can inform decisions about hiring and career advancement for this reason social media accounts are carefully curated in order to highlight expertise and to enhance likeability allowing professional contacts to access social media posts is a form of selfdisclosure which can both promote and damage professional relationships many social media studies adopt the bideology of openness which suggests that effective communication relies upon the maximum possible degree of transparency in this view organisations can reap substantial benefits if actors are willing to share information about themselves and their work in fact it is what social media conceals as well as what it reveals that can be of great advantage in a professional setting the dominant assumption in social media studies is that the platforms provide actors with a degree of control over how they are perceived by their professional networks a major advantage for professional users is that information presented can be carefully considered and edited allowing individuals additional control over what is communicated conversation threads and posts remain visible long after an interaction has taken place and can be viewed by many others making careful deliberation an even more pressing issue the enduring nature of posts can be especially advantageous in a professional setting where they may be accessed over an extended period of time by many intended and unexpected viewers in large geographically dispersed organisations these networks have fostered connections and collaborations that may not have occurred otherwise as well as giving individuals the opportunity to transcend the usual limits of time and space the disparate sources of information highlight characteristics that might otherwise be challenging for individuals to share in a professional setting attributes that might be viewed favourably on their own do not always sit comfortably together for example a person may wish to be thought of as both competitive and warm social media can communicate characteristics implicitly by inference removing some of the burden placed on individuals to explicitly exhibit juxtaposing traits the challenges of communicating in this way emerge because it can be difficult to control the types of information made available via social media individuals are not the only ones contributing information to their social media accounts they can also be tagged in photographs or posts added by other people algorithms also selectively curate what can be viewed these circumstances increase the possibility that information from one life domain may spill over into another in concert these bits of information help to infer what a person is like managers have been shown to traverse personal social media accounts to find out about potential employees and to check the behaviour of current hires social media snooping becomes problematic if the information made visible to professional contacts alters favourable perceptions of a person there are many examples of employees that have been fired after posts made to private accounts became visible to their employers a classic example is that of the employee who posts disparaging remarks about their boss on social media only to be fired when the boss finds those posts different cultural and organisational contexts render different behaviours contextually inappropriate making it very challenging for individuals to anticipate the standards by which their posts might be scrutinized if the social cues that inform interaction and behaviour are not visible or if they are misjudged then inappropriate posts can be made visible to colleagues altering their perceptions of an individual indeed multiple contradictory selves can seem to exist in a bfragmented electronically mediated environment different coping strategies are used to minimise these potential threats individuals employ a range of boundary management techniques to try and prevent their personal lives from spilling into the professional domain these include selfcensoring modifying privacy settings and the creation of multiple profiles current studies focus squarely on efforts to separate life domains and manage social boundaries on social media but thus far give little attention to the intentional use of personal social media content in a professional setting we argue that individuals are increasingly creative about their online selfpresentations because they want to stand out our findings show how information from personal and professional social media accounts is drawn together to signal favourable personal characteristics to others at work following other social media studies we turn to the sociological literature for a theoretical explanation of how social media posts are used to form inferences which subsequently effect the social judgements that shape everyday life inferences and social judgements inferences play an important role in how actors understand each other and their social situations to infer is to arrive at a judgement or conclusion based on discernable evidence inferences are arrived at in the mind of the observer but informed by information provided by the observed inference particularly informs social interaction in settings where information is incomplete or imperfect there are many examples of inference at work in everyday organisational life an employee may call in sick but arrive back at work with a sun tan possibly leading to the inference that she spent time at the beach a colleague may stay late compliment the boss and take on extra work from which her boss may infer that she wants a promotion studies of the use of inference in organisational settings have focused on the requirement for one party to read between the lines in order to understand the other and take appropriate action the abilities necessary to engage in inferential work are thought to be social and interactional rather than individual and cognitive ones since inference relies heavily on subtle cues that evade straightforward categorisation for example judgements may be formed based on age ethnicity and family status as well as less tangible factors such as the way another person deports themselves in terms of gesture and tone while these characteristics are complex to decode in facetoface interaction the difficulties can be compounded in a technologically mediated interaction in these settings information asymmetries abound requiring all parties involved in a communication to engage in some degree of inferential work geographically dispersed teams that may never meet each other facetoface are obliged to form inferences based on the information made available via social technologies even those who normally work in the same physical environment can supplement their everyday social performances with information posted to their social media profiles thus social media inferences are formed as information available via profile pages and posts is used to make judgements about a persons character and capabilities research on selfpresentations has highlighted the central role of the audience in determining these professional selfpresentations when deciding how to present themselves actors account for the various qualities of their audience in particular their significance bby virtue of their power attractiveness expertise and number the status of the audience in relation to the actor determines the extent of their influence on the subsequent selfpresentation in the presence of a high status audience the actor becomes increasingly concerned with giving a performance that will foster a favourable impression while annexing information that might contradict the performance out of view in organisational settings these powerful audiences are the managers and chief executives that determine the career trajectories of those with lower professional status these influential audience members form opinions based on the performances they observe and exert their influence over subsequent outcomes for the actors they may draw inferences based on a wide variety of social cues intentionally given and unintentionally given off thus the actors behaviour is noticeably adjusted to reflect appropriate and desirable social norms these norms are shaped by powerful institutions and cultures at a societal level and can vary dramatically across contexts in order to function successfully in their organisational context actors need to understand the implicit norms constituting the social order in their local setting and what part they should assume in the larger ongoing performance of social life these macro and micro cultural norms shape local attitudes about what can be appropriately disclosed by professionals both in and out of the workplace by introducing accounts about the use of social media as a source of rich multiple inferences our empirical sections provide insights into the preoccupation with inferences in professional selfpresentation the narratives suggest that these sources of inference can provide a valuable tool for career advancement yet are risky since they are difficult to control our analysis focuses on how actors cope with this tension by drawing together information from different life domains rather than drawing boundaries between them methods we adopted an interpretivist viewpoint which bdoes not predefine dependent and independent variables but focuses on the complexity of human sensemaking as the situation emerges from this viewpoint the same physical institution artefact or human action can have different meanings for different human subjects as well as for the observing social scientist as researchers we were involved with the respondents in the process of negotiating the meaning of the data and the conclusions drawn reflect this combined effort this study is based on data collected from qualitative interviews with 31 indian it professionals who had a graduate degree or above in the sections that follow individuals have been given pseudonyms in order to preserve anonymity this research setting was chosen since it is an example of a crowded and hyper competitive industry in which it is extremely difficult for individuals to stand out and gain recognition we focused on indian it professionals who we assumed would need to engage with social media in creative ways to get ahead given the technological nature of their expertise we expected them to be using social media in advanced and interesting ways initially we used purposive sampling techniques to identify participants that were likely to be engaging with social media for professional purposes we then used snowball sampling techniques to encourage recommendations from participants a call for participants was also shared via the social media platforms used by the respondents we sought to include it professionals from both multinational companies and indian it companies in addition to interviews field notes were produced in the process table 1 shows the spread of interviews with respondents across four basic categories manager program analyst associateprojects and human resource manager each interview was conducted in english and lasted roughly an hour during which the participants responded to questions about their use of social media for professional purposes respondents spoke at length about their experiences of interacting on social media with colleagues clients and other professional colleagues they also reflected on potential consequences for their careers respect and liking by workplace colleagues and the resulting impact on their image at the workplace further respondents spoke about anxieties fears and cognitive demands when interacting online the need to control managerial interference was a dominant theme which exacerbated the participants anxiety when interacting with professional contacts on social media following a qualitative inductive method data analysis and transcription occurred simultaneously throughout the data collection period through this process we achieved theoretical saturation that is no additional themes emerged with additional data we began our analysis by reading and summarizing each interview in order to identify recurrent themes across the data set we identified a coding unit as a complete sentence or series of complete sentences that constituted a single semantic unit we generated a large number of codes during this process which were gradually reduced as we combined codes with the same meaning and excluded those that had no relevance to the research question from our list the second column of table 2 summarizes the codes established during this process having established these themes we engaged in further open coding to arrive at more abstract interpretive concepts which are summarized in the third column of table 2 these concepts enabled us to arrive at theoretical explanations for the harnessing of social media inferences the potential pitfalls of using social media and the making of judgments about how to use social media appropriately in the findings section that follows we use the interpretive concepts as subheadings under which we group the thematic codes the participants spoke about using social media to create an image or impression that would impress their professional colleagues and help them to stand out in the work place they did this by establishing rich descriptive profile pages posting pictures and networking with other colleagues on social media they exerted these efforts in order to foster impressions in the minds of influential others some of whom they had not met yet the participants nurtured these impressions as the different bits of information about them on social media were pieced together to form a picture it was not always easy to manage the impressions being formed since the information available about the participants came from a wide variety of sources in some instances work colleagues became privy to information and images that were not deemed appropriate in a professional context this typically occurred when individuals dropped their guard and slipped up negative inferences could also be made when other people made posts featuring the participants that were considered damaging to their professional reputations the potential for social media to both enhance and damage their professional images triggered some reflection about how to best use social media the participants attempted to avoid damaging mistakes by engaging in cognitive reflection and imaginative techniques that served as selfchecking mechanisms these reflective moments allowed them to audit how their social media profiles were representing them professionally they also mentioned the role of others in regulating how elements of private life could be brought into a work context findings harnessing social media inferences the idea of promoting oneself online was well established for the technologically inclined it professionals in this study most made use of a wide variety of blogs forums and social media sites to endorse their expertise and professional achievements together these sources of information formed a professional image of who the participants were and what they were capable of they were particularly keen to use their posts to attract the attention of influential others who could advance their career prospects you post online to just acknowledge that you are an expert…another reason could be that you are actually looking for other prospects and you need to advertise the fact that here you are worth something you know this you know this stuff and if this is what people are looking for then you are the person to come to this was not easy to accomplish since many of their counterparts were also using the same tactics the result was a busy and crowded online environment in which it was tricky to get noticed under these circumstances the participants became more creative drawing in additional sources of information that could add to the overall picture they presented of themselves online these sources were not directly related to their professional lives rather they originated in their lives outside of work the participants used these additional sources to add interest to their professional profiles and to stand out from the crowd in positive ways creating images the participants suggested that it was no longer possible to get noticed by expressing professional opinions and sharing knowledge since most people in the industry did this they talked about using social media to construct images of themselves that included additional dimensions that would appeal to their employers social media becomes a tool for others to understand you as a personality im very conscious about that so i use twitter to express my opinion in a way that reflects my personality through which people understand who i am most of the participants referenced the opportunity to express their personality on social media in addition to the difficultly they had with getting noticed they also said they worried about the dominant impression that software coders were boring social media gave them the opportunity to show additional sides of their lives while these did not directly relate to their daytoday work they did highlight favourable aspects of their personalities that could appeal to colleagues at work they opened up information about their interests outside of work and how they spent their free time they also allowed colleagues to access information about who else they were connected to and what kinds of conversations they were having they felt that these additional sources of information reflected favourably and added to the over all impression that they were good people to work with the about me is one section where people write elaborate things you have your interests you have your hobbies your music the kinds of things you comment on the kind of likes that you have the kind of posts that are generated by you it speaks a lot about you these social media sources were not directly about work but babout me and the participants recognised the potential for narcissism they observed that on occasion their colleagues would go to great lengths to construct a social media profile that looked cool they included pictures and videos from their leisure time they commented on current affairs and popular culture they showcased their hobbies many found that this helped them build a rapport with their work colleagues and superiors they felt that sharing this level of detail enabled them to present a wellrounded view of themselves they were no longer just coders but coders that also ran marathons enjoyed photography or ran side businesses they hoped these elements of their private lives would reflect favourably and help them to get noticed they opened up these personal details to their work colleagues by adjusting their social media privacy settings and inviting those they worked with to link up you add people as connections because its an additional glimpse of you that they can see apart from what you already told them they did not need to communicate everything about themselves directly in facetoface conversations because their profiles added glimpses into their lives that inferred positive things the participants said that they felt their coworkers attitudes towards them changed as they got to know more about them through social media some of them also enjoyed seeing their relationships with their bosses become slightly less formal they felt that they gained favour with the management by allowing them to access the social media profiles that they had built using social media afforded them the chance to share other aspects of their lives that fostered favourable impressions in the minds of their colleagues forming impressions the participants explained that the main reason they put effort into building a professionally appropriate social media profile was in order to foster favourable impressions in the minds of their colleagues they recognised that they formed impressions about others by gathering additional information on social media and they assumed others would find out about them in a similar way they said that often colleagues accessed each others personal social media accounts out of curiosity but that these informal investigations of each other often had implications at work by incrementally posting information about themselves for their colleagues to see they hoped to foster favourable impressions they wanted to emphasise while they were committed to work they were not onedimensional to showcase their creative persona they not only posted about work related issues but included pictures and posts suggesting that they were just as involved in their out of work interests and that they had a lot going for them since it was difficult for them to meet and get to know everyone in their large geographically dispersed organisations they often used social media to foster impressions with those they did not know well there are a lot of people from other locations who cant meet you so they have to form an impression of you solely through what you write or through your communicator the participants felt that as social media had become more ubiquitous it was more common for people to form impressions about them based solely on their online profiles in some instances they felt that this was positive since social media could enable impression building that could not otherwise occur they were very unlikely to physically meet colleagues in other locations but they could get to know one another through their shared associations on social media as social media use increasingly became a feature of their working lives they felt that they were expected to allow even those they had never met to connect with them this made visible not only what they were posting themselves but also what others were saying about them they recognised that there were advantages to making use of the many different forms of inference available on the platforms your work people see what other people say about you so to that extent its more truthful than a resume would turn out to be while they considered it useful to be associated with positive posts and comments from others there was also some uneasiness they recognised that they were not entirely in control of the information associated with their profiles on social media potential pitfalls socially unacceptable while the participants hoped to gain advantages by sharing their personal lives on social media they also recognised that there were disadvantages to being so open for example it became challenging to anonymise their remarks which meant they had to be increasingly cautious about what they talked about in their posts one of my colleagues went on facebook and said something derogatory about salary raises without mentioning the company name but everyone knows who you work for so these things are not accepted the participants talked about how oppressive it could sometimes be when everyone knew the details of your life it became difficult to slip out of the office to make excuses for behaviour or to share honest opinions although they had previously been accustomed to using social media to vent their frustrations or to be more candid in their comments since they had begun to use their personal social media for professional purposes this was more difficult to do it was not easy to prevent their bosses from seeing what they had posted it was simply not socially acceptable to make negative remarks relating to work the participants sensed that senior management checked their social media posts with the intention of reprimanding them for inappropriate behaviour i was called in for voicing my opinion against one of the polices that was hitting my training batch mate and myself we were called directly and asked byou dont want to lose your job do you i got really scared and after that i changed the way i wrote my posts the participants were uncomfortable with the thought that social media could be used as a form of surveillance the implications of their bosses being privy to some of their comments or practices worried them in a highly competitive industry they knew that if they slipped up they could easily be replaced while they were confident that what they posted to their professional blogs and work facing sites was appropriate they were less certain about the personal social media posts that they had given their colleagues access to the fear of being caught out on social media was intensified by the fact that others could post things about them they spent a lot of time considering how they might avoid offending or upsetting their superiors i went on vacation recently and was very scared to take leave from my boss even though they were able to adjust their social media settings and privacy controls there was still a high level of anxiety that with the fluid connectedness of social media they could miss something that would damage the selfpresentations they were trying to promote they recognised that there were a number of different ways in which their associations with different people and information on social media could be damaging to their reputations damaging associations the participants did not feel that their social media connections would intentionally sabotage their professional impression management efforts it was the small details that could be pieced together to form inferences that they were most concerned about in an out of work context it would not be damaging for friends to share pictures of silly or relaxed behaviour but if these pictures became visible to a professional contact via social media this could potentially contradict the impression that the participants wished to foster if your manager had a particular view about you you wouldnt want that to change because of one silly picture it might not be on your profile it could be on somebody elses they emphasised that it would not take much to damage the perceptions others had of them it was difficult for them to anticipate the diverse ways that such damage might occur many of them considered different potential scenarios in which a picture or a comment might suggest something unfavourable to their manager they felt that there was a possibility that their managers could make connections between what was happening at work and what they saw happening on social media supposing you have not been able to perform well for some reason for the past 23 months or a quarter so if hes like narrow minded and not broadminded he would link that to saying you are out too much your mind is deviating you are not concentrating i see judgements being passed based on facebook everything is indirectly linked to there they recognised that many people formed judgements based on information from social media they felt that the problem with this was that social media could not offer the necessary context for forming correct judgements furthermore the attributions of cause based on social media posts could have profound implications for peoples professional lives however superficial these associations might be if you were to post a picture of yourself with a cigarette and a drink in your hand or acting silly people are going to draw a lot of inferences and thereby when they see you at work they are not going to take you seriously the pictures and posts made visible to professional colleagues had to fall in line with the expected norms of behaviour if the participants were to be taken seriously they felt that while they wanted to show a more interesting side of themselves on social media there were limits to what they should display they could not allow their on line profiles to go beyond the bounds of what was considered to be appropriate in their particular cultural context to be associated with smoking drinking and partying was considered particularly unappealing they recognised this and attempted to annex such behaviour to their private social lives they gave considerable cognitive effort to repairing the reputational damage that might occur if such behaviours came to the attention of their managers making judgements selfregulating the participants developed a sense of caution as they realised the level of complication involved in controlling professional impressions on social media while they were still keen to build their online reputations in this way they were less certain about how to limit the associated risks they became less spontaneous as they accumulated social media connections at work knowing that these people could now see details of their private lives your colleagues are on facebook your friends are on facebook so you become very circumspect in what you say or do they hesitated in response to their concern over the potential pitfalls they might encounter these pauses provided moments of necessary reflection during these instances they made their own judgements about the information associated with them on social media they considered how different pictures and posts might be interpreted by their associates the sprawling interconnected nature of social media meant that often this kind of contemplation became an extended exercise i think twice thrice four times before i tweet something until im completely sure many of the participants recognised that their prolonged reflection was contrary to the commonly understood design of sites like twitter they understood that many of these social media sites were intended to involve responsive and immediate posting yet they found that giving themselves space to prepare became vital to retaining a sense of control over their social media images they asked themselves many questions about the content of their posts examining each from different moral and social perspectives i would say that it does help to look inside be introspective take a step back and consider whether the way you are interacting with people is right their feeling that there were right and wrong ways to do things governed what they included in their social media selfpresentations in part they based their judgements on how well a post helped to support the predetermined image they wished to present if the picture or comment did not contradict the intended impression then in one sense they deemed it to be appropriate the boundaries between what was right or wrong also shifted in relation to the different groups of people they were connected to this was trickier for them to manage since different colleagues responded favourably to different types of posts navigating this challenge require a great deal of imaginative effort socially regulated the participants sensed that in their large organisations there were potentially hundreds of people watching them via social media they saw this as simultaneously a source of pressure and great opportunity they harnessed this idea as a cognitive tool for coping with the social pressure of interacting on social media many said they imagined different potential audiences as a way of roadtesting their posts so imagine you are sitting in front of your audience and everyone knew you personally and then say what it is you wanted to say the act of imagining their social media audience enabled the participants to anticipate how their posts would be received this technique rendered the process of making social media posts less abstract they understood how to interact with managers and work colleagues in facetoface settings and their acts of imagination helped them to apply the same rules to their social media interactions on occasion some participants found that social media altered the dynamics of their relationships with their managers allowing them to engage in less formal conversations however on the whole they realised that they had to observe the same social norms and rules as existed in the real world they said they came to this understanding as they were corrected by and corrected other peoples social media behaviour the answer is to teach people to police themselves thats what happens on blogs where bloggers tell each other what is alright even on the internal bulletin board its selfpolicing otherwise it wont work you are not in any random network this could define your career so act responsibly most people do and if they do not they are pulled up and they learn as colleagues helped to regulate eachothers behaviour the participants felt that there was some understanding that there could be mistakes minor errors were tolerated but people were expected to learn and adjust their behaviour more serious mistakes could be career defining these involved major breaches of the established social conventions within an organisation during their periods of reflection the participants kept these implicit rules in mind reminding themselves that posts about bunking off work or engaging in activity contrary to the values of their organisation could cost them their jobs always keep in mind that even when you dont think about it the companys image is at stake one way or another which is fair if you keep in mind that even if you are not talking about them directly one way or another you are representing the firm you should use your good judgement and then you wouldnt do certain things during their periods of contemplation they drew upon their understandings of organisational values some recognised that their social media selfpresentations should complement the image of their organisations or at least not contradict it their organisations became significant entities in their own rights as the participants imagined various social values with which they needed to comply by imaginatively engaging with social actors and values they felt better prepared to anticipate the implications of each social media post and to retain control of the impressions created by their social media posts discussion our study shows how individuals make use of social media to generate favourable inferences that help them stand out at work while many studies have adopted a sociological perspective in describing the measures taken to delimit professional and personal social media accounts only recently has the intentional blurring of these boundaries been acknowledged these developments suggest a growing level of sophistication and savviness on the part of users who aim to benefit by using social media in creative ways our findings complement these recent studies and add additional nuance by reconceptualising social media performances and elaborating upon the cognitive underpinnings that support them our findings both engage with the wellworn metaphor of social performances and raise new questions about the type of performance social media affords several studies have applied dramaturgical vocabulary to social media use debating whether these performances take place on a formal front stage a relaxed back stage or simultaneously both questions about how actors separate different audiences and cognitively deal with conflicting social norms have dominated early understandings about how social media are reshaping organisational communications difficulty in applying the dramaturgical metaphor has led some to question whether these are performances at all or whether they more closely resemble other forms of expression such as art galleries although participants are clearly engaged in social performances of the self on social media there could be some limits to the applicability of goffmans concepts since his ideas rely heavily on the notion of a boundaried space his conceptualisation is based on the format of classical theatre which requires audiences and actors to each play their part in suspending belief and engaging in an alternate reality in order to achieve this state the mechanics supporting the performance and any contradictory or distracting material is removed from view this treatment of selfpresentations is increasingly difficult to apply in the age of social media when the boundaries between different styles of performance are more difficult to identify and control under these circumstances it can be challenging for both actors and audiences to know what kind of performance is taking place and what their response should be elaborating upon our findings we suggest that the challenges in applying this metaphor may in part be attributed to our narrow view of what constitutes theatre rather than discarding the performance metaphor we propose that the inclusion of additional theatrical forms to the theoretical framework can refresh and supplement our understanding of social medias role in self presentations based on our data we propose an alternative view of social media presentations as postmodern performances akin to forms of theatre that blur the boundaries between the front and backstage to remind the audience that a performance is merely a representation of reality not reality itself similarly our participants brought content that would typically be consigned to life outside of their organisations into their social media performances by including their personal interests and experiences in their professional performances they reminded their colleagues that there was much more to them than could be seen at work as one participant quipped bi posted an old photo of me with a ponytail and our junior team mates came and said bi really didnt know you were that much fun so its all about helping people to see the bigger picture of who you really are many examples of this style of performance can be found on the social media accounts of public figures for example former president of the united states barrack obama includes informal photographs and family pictures on his official twitter account along with the description bdad husband president citizen these boundary spanning performances are nicely articulated in the work of bertolt brecht who employed a wide variety of techniques in order to stimulate audiences to think about how a performance related to their broader lives in particular he would have actors drop out of character and address the audience as themselves use explanatory placards have stage directions read out loud and many other techniques that intentionally blurred the boundary between conventional front and back stage domains social media enabled our participants to enact similar styles of performance allowing them to drop their formal performances temporarily although like a postmodern troupe they were still performing this was a different style of performance still intended for a formal audience but designed to guide them in drawing new conclusions by revealing information normally related to the backstage these glimpses fed into front stage selfpresentations although they were not traditionally associated with that realm we argue that social media presentations can be conceptualised as postmodern forms of performance in which individuals can intentionally disrupt the boundaries between front and back stage to infer meanings that may not be possible in a traditional organisational performance settings these hybrid performances were very demanding for the participants most notably by disrupting the boundaries between front and back stage information they relinquished a measure of control over what could be viewed by their formal audience they were hypersensitive to the risks of this approach since in many cases the status of the audience they were addressing was high in comparison to their own while this kind of social media performance enabled them to communicate things by inference that they could not have done otherwise there were also limits they did not want what was revealed on social media to completely disrupt the ongoing performance of social life in their actual work settings for instance many participants referred to certain types of content that could cause offense or argument with their colleagues such as political or religious opinion and other socially sensitive material the stakes for triggering these types of conversations at work were potentially very high they were constantly alert to the rules and norms of the prevailing social order in their physical work settings the popular affordances approach to social media implies that its uses are limited only by users imaginative interpretations and the capacities of the technology our study draws attention back to the still powerful real world context in which posts are viewed while social media may allow users to disrupt the boundaries between front and backstage performances in these settings the social order that regulates behaviour retains primacy concerted mental effort was required lest the participants forget the governing rules of the social order and become carried away in what they shared as both formal and informal material become part of the ongoing performance of self the private space for unchecked selfexpression is squeezed since they perceive these performances to be high stake activities participants can experience intense pressure interestingly rather than withdrawing their personal posts and resuming strictly separated styles of behaviour our participants coped by creating a third cognitive space that was neither a formal front stage nor a completely relaxed back stage the participants imagined the potential audience for their posts or forced themselves to pause and think two or three times about the content they were about to share many of them used the term introspection to describe the time and cognitive space they needed for their social media performances this was more like a liminal mental state in which the actors prepared themselves for their performances akin to mental warmups this liminal state allows actors to imaginatively address their audiences test material and consider its appropriateness the creation of a liminal preparatory space is crucial in enabling performers to cope with a boundaryless performance space our data captures the fleeting moment alluded to by goffman when an actor transitions from a back stage to a front stage state recent studies have highlighted the potential challenges that arise as different social domains collide on social media these difficulties have been associated with the polarisation of formal and informal contexts and social media posts in light of our findings we propose that in a social media age these categories are becoming less absolute aided by social media technologies they can be actively unsettled by actors and organisations indeed it would appear that actors are not necessarily always compelled to disclose their personal lives but instead are opting to become increasingly transparent as they engage in these postmodern performances of the self we propose that the mastery of a transitional liminal state is key to coping with the increasing openness demanded by organisations and practiced by individuals concluding remarks in conclusion this paper complements studies that assume individuals separate their different life domains on social media the findings suggest an increased willingness to voluntarily selfdisclose in a hybrid style of performance conceptualised above as a type of postmodern performance this shift in performance style generates a number of interesting avenues for further investigation future research could focus on questions pertaining to performers engaged in an increasingly boundaryless space when presentations are no longer conceived of or sustained by multimember teams investigations might focus on how oneman teams sustain and appraise the effectiveness of their own performances they might also introduce insights into how postmodern performances are received by social media audiences this paper also contributes to the discussion about social media selfpresentations by introducing the importance of a liminal mental state in coping with the increased levels of selfdisclosure associated with these types of performances professional selfpresentations are becoming increasingly demanding in a social media age that has embraced the ideology of openness as the default position the converging pressures of an increasingly competitive job market along with the boundary blurring presentation space afforded by social media are shaping organisational norms related to selfdisclosure our data suggests that while social media are being embraced in practice as a rich source of inference individuals can also maintain a disciplined approach to these performances by engaging with a liminal mental state to help them to prepare for their social media performances while our participants used these cognitive socially informed mechanisms to prevent them from crossing a perceived line and disclosing too much recent examples suggest that actors could intentionally reveal too much for example president trump in reference to his controversial comments on twitter said bwithout the tweets i wouldnt be here such an example suggests that while this study acknowledges the importance of the social order in establishing a line of appropriate social media disclosure future studies might fruitfully investigate professional choices to intentionally cross the line from a managerial perspective it is interesting to note that individuals appear to be engaging in this type of hybrid performance and associated selfdisclosure voluntarily studies suggest that the inclusion of personal information and informal interaction in a professional setting can enhance knowledge sharing and have other organisational level benefits there is little evidence that organisations are adequately tapping into or stimulating this type of social performance of self such performances should be an area of burgeoning interest to managers our data was collected in an intensely competitive job market where individuals were compelled to look for creative ways to stand out by drawing in a rich array of inferences on social media we acknowledge that in less competitive settings the same degree of selfdisclosure may not be necessary indeed a handful of our participants were still able to optout of these types of hybrid selfpresentations however we would argue that in a global economy markets are forecast to become more not less competitive and we anticipate that workers in many industries will find it necessary to do creative things to stand out also since our data is not longitudinal it is not possible for us to judge the extent to which social media behaviours become more creative and riskier over time the degree to which social media selfdisclosure norms drive increasingly risky and creative selfpresentations is an interesting avenue for future studies michelle richey is a lecturer in technology and entrepreneurship in the school of business and economics loughborough university her research relates to how entrepreneurs and those in small firm settings make sense of and communicate their experiences particularly in the context of the digital age her research has been published in international peerreviewed journals including information technology and people and technological forecasting and social change

in addition to their professional social media accounts individuals are increasingly using their personal profiles and casual posts to communicate their identities to work colleagues they do this in order to stand out from the crowd and to signal attributes that are difficult to showcase explicitly in a work setting existing studies have tended to treat personal posts viewed in a professional context as a problem since they can threaten impression management efforts these accounts focus on the attempts of individuals to separate their life domains on social media in contrast we present the narratives of professional it workers in india who intentionally disrupt the boundaries between personal and professional profiles in order to get noticed by their employers drawing on the dramaturgical vocabulary of goffman 1959 we shed light on how individuals cope with increased levels of selfdisclosure on social media we argue that their selfpresentations can be likened to postmodern performances in which the traditional boundaries between actor and audience are intentionally unsettled these casual posts communicate additional personal traits that are not otherwise included in professional presentations since there are no strict boundaries between formal frontstage and relaxed backstage regions in these types of performance a liminal mental state is often used which enables a better assessment of the type of information to present on social media

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matthew smith 7 1 thompson rivers universitykamloopsbritish columbiacanada2 arizona state universitytempearizonaunited states3 rutgers universityjacksonnew jerseyunited states4 clemson universityclemsonsouth carolinaunited states5 drexel university college of nursing and health professionsphiladelphiapennsylvaniaunited states6 university of washingtonseattlewashingtonunited states7 texas a m universitycollege stationtexasunited states mentorship is vital to supporting professional growth among early career faculty members working with the gerontological society of america the advancing gerontology through exceptional scholarship program was created as a mentorship model to promote productivity and peer support for early career faculty members this presentation will 1 describe the ages program as a prototype to facilitate peer support collective learning productivity and coauthorship opportunities to advance early career faculty members and 2 identify effective strategies to facilitate other groups looking to develop highquality mentorship and training programs to support early career faculty members after a competitive process a cohort of 7 ages members partook in monthly workshops from november 2022 to june 2023 drawing on our experience with the ages program we identified four strategies that cultivated our ages program 1 being adaptable to address mentorship needs 2 establishing accountability measures to enhance productivity 3 fostering collective learning and peer support and 4 delivering inspirational and educational activities following on the completion of the ages program an open discussion was held with the cohort to assess and critically reflect on the program discussion results indicate the ages program was valuable in supporting early career faculty members specifically findings demonstrate that the program was perceived as successfully supporting team science collaborative opportunities and enhancing productivity next steps are to conduct an anonymous evaluation survey to identify specific areas to strengthen and enhance the program for future cohorts abstract citation id igad1043167 age as a factor in diversity equity and inclusion initiatives in higher education natalie galucia and nancy morrowhowell washington university in st louis st louis missouri united states at institutions of higher education demographic shifts in the population and the growth of diversity equity and inclusion initiatives are occurring simultaneously this study seeks to understand their intersection by focusing on age as a diversity factor in dei initiatives on college campuses six focus groups with a total of 42 dei staff members were convened including 36 collegesuniversities across the country thematic data analysis was conducted by three members of the research team who reached consensus on themes subthemes and representative quotes focus group participants suggest that age as an identity factor is not given much attention in dei initiatives participants acknowledge the issue of age but in general they strive to keep other identities like race and gender in the forefront especially in the face of low resources these findings can be understood in the context of the current political environment around social justice issues and the pervasive ageism at the society level especially in agesegregated institutions of higher education while it may be difficult to elevate age in dei initiatives on campuses interventions were identified and advocacy efforts may move us toward advancing age diversity equity and inclusion in higher education as well as other organizations tied to domains of potential social exclusion for older adults we automated the collection of old person and young person images in midjourney the texttoimage prompts yielded 456 aigenerated images that were analyzed with amazon rekognition image detection software to transform them to quantitative data data were compared statistically using stata the results show that the images of older people are significantly less bright and less sharp than the images of younger people additionally images of older people have significantly more smile expressions and are more likely to be wearing glasses compared to images of younger people the findings reveal that midjourneys algorithm associates older people with a negative sense of antiquity irrelevance and dread the findings also align with the stereotype content model in which older people are seen as having warm personalities but not as competent or capable as younger people we interpret these results as age bias that the ai art generator midjourney has learned and in turn creates through image generation abstract citation id igad1043169 age differences in emotion regulation and executive function wei xing toh 1 and hwajin yang 2 1 nanyang technological university singapore singapore 2 singapore management university singapore not applicable singapore agerelated improvements in emotion regulation are thought to account for the relatively healthy levels of wellbeing observed in late adulthood however extant laboratorybased evidence on age differences in the effective implementation of er strategiessuch as reappraisal and distraction remains equivocal moreover developmental differences in er monitoring and factors that underpin such agerelated differences are poorly understood therefore we investigated how younger and older adults differ in the implementation and monitoring aspects of er and how executive function a collection of higherorder control operations that underlie er processes could explain such agerelated differences in er using a comprehensive battery of nine ef and two er tasks results indicated agerelated decline for the implementation of reappraisal but not distraction for monitoring advancing age was associated with a less flexible pattern of strategy maintenance and switching across highand lowintensity emotional contexts importantly these agerelated differences in er implementation and monitoring were significantly mediated by declines in ef thereby alluding to the role of ef as a potential mechanism our findings suggest that certain er processes are more cognitively demanding than others and that ef could be a viable target of intervention to improve such er processes in late adulthood military veterans often experience a range of sleep disorders that significantly impact their physical and psychological wellbeing current study describes prevalence and age differences vs across insomnia obstructive sleep apnea nightmare disorder and posttraumatic stress disorder vietnam veterans completed a survey of their sleep experiences and ptsd as part of a crosssectional study veterans were mostly white male from the army with some or twoyear college and currently married insomnia was screened positive in 277 of the veterans osa in 586 nd in 57 and ptsd in 186 there were significant mean differences in insomnia and ptsd across age groups 243 p 016 and 206 p 04 respectively with younger age group showing higher insomnia and ptsd there were no significant mean differences in osa and nd pearson correlation analyses yielded important associations insomnia was significantly positively correlated with ptsd osa and nd ptsd was significantly positively correlated with osa and nd nd was significantly positively correlated with osa there were no significant differences in the associations across the two age groups recognizing and addressing various sleep disorders and comorbid ptsd are crucial to improving the quality of life of veterans results emphasize need for comprehensive assessment of sleep disorders and ptsd among veterans

in 2016 the centers for medicare medicaid services cms introduced advanced care planning acp services current procedural terminology cpt codes 99497 first 30 minutes and 99498 additional 30 minutes this enabled healthcare providers to seek reimbursement for discussing future medical care preferences when patients are unable to make decisions in this study we linked administrative claims and encounter files for the 2238611 medicare beneficiaries who died in 2019 of these 177 395258 had a billing code for acp services in 2018 or 2019 among feeforservice ffs beneficiaries 188 had acp services billed compared to 157 of medicare advantage ma beneficiaries most acp encounters were for the first 30 minutes of services 91 ffs 90 ma among ffs beneficiaries most acp encounters were attributed to internal medicine 308 family medicine 126 and nurse practitioners 299 and took place in hospitals 476 skilled nursing facilities 184 and office 142 settings location of acp services was available for only 8 of ma encounters hospitals 403 skilled nursing facilities 182 and office 201 additional findings will be presented regarding variation in acp encounters by raceethnicity and geographic region state ruralurban community area deprivation index that enhance our understanding of acp service use at the endoflife for medicare feeforservice and medicare advantage beneficiaries

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introduction the backtrack program was established in armidale in northern new south wales australia in 2006 for 1417yearold high risk young people it is underpinned by six key principles derived from previous reviews of the literature 12 together with feedback from staff 3 in recognition that its participants are more likely to engage in multiple risk behaviour the program is comprised of multiple components that target different areas of need simultaneously flexibility in the delivery of the program components which reflects that the focus of young peoples needs shifts over time flexibility in program attendance so that participants are able to start leave and reenter the program as they wish or as their life circumstances permit a requirement that young people in the program eventually actively participate in all components of the program active engagement of local businesses local media key stakeholders and community members in delivering program elements resolving bureaucratic problems providing infrastructure and funds and facilitating communication about the benefits of the program and recognition that achieving sustained change among highrisk young people will take a number of years the backtrack program comprises a range of activities organised into five standardised core program components effective engagement to optimise participation in the program individualised lifeskills management to address participants immediate and practical needs such as attending court or finding secure housing diversionary activities to reduce participants exposure to highrisk situations such as nighttime encounters with police in public places or volatile situations at home personal development identity and team identity to improve participants social and emotional wellbeing increase their range of personal coping strategies and to enhance their sense of connection to their peers and community and learning and vocational skills to increase their opportunities for active participation in education or training likely to lead to employment this model of standardisation with inbuilt flexibility provides a mechanism to both standardise the intervention across multiple communities and tailor it to the resources available in different communities further details of the backtrack program can be found on the backtrack website and other sources 4 participants in the backtrack program are typically at a high risk of drug and alcohol harm psychological distress and suicide the eligibility criteria and the procedure for referral and acceptance into the program are detailed elsewhere 3 briefly young people are eligible to participate in the service if they resided in a community where the service was available were aged 1421 years and were currently experiencing more than one of the following behavioural risk factors involvement in criminal activity substance use violent behaviour homelessness poor mental health and wellbeing poor engagement with school and unor underemployment all program participants report experiencing risk factors in at least two domains of risk and more than half experience risk factors in all four domains 3 the most common risk factors were involvement in crime or with the juvenile justice system school absence unemployment suicide ideation psychological distress substance use low levels of physical activity and low health service utilisation 3 the presence of these risk factors places these young people at both shortterm risk of harm and longterm risk of entrenched unemployment criminal involvement and incarceration 5 6 7 8 9 recent research has suggested that one in three serious young offenders strongly endorsed the view that crime had become their way of life with age of onset and frequency of offending reinforcing this view 10 in addition to personal hardship the harms experienced by these young people have a negative impact on their communities through increased social disruption potential loss or damage to property fear for personal safety and increased health costs as well as police court and incarceration costs 1112 given this impact on both individuals and the community it is important to consider community value when evaluating the effectiveness or conducting an economic evaluation of a program like backtrack such views have the potential to impact on program uptake funding sustainability and estimates of its benefits despite the importance of economic evaluation a systematic review of communitybased programs for highrisk young people found that no published evaluations to date have conducted an economic analysis or systematically quantified the costs or economic benefit derived from such programs 2 the aim of the current study is to address this lack of data and seeks to explore community value and preferences for reducing youth crime and improving community safety using backtrack in a rural setting in armidale new south wales australia materials and methods discrete choice experiments provide a useful method for quantifying preferences for nonmarket goods and services 1314 dces are based on the premise that any good or service can be described according to its attributes and the levels of these attributes determines the relative value they place on them respondents in a dce must choose their preferred option from a group of hypothetical scenarios called a choice set it is proposed that aligning health care policy with patient or community preferences could improve the effectiveness of health care interventions by improving adoption of satisfaction with and adherence to clinical treatments or public health programs 15 the application of dces has increased rapidly over the past decade and has been successfully applied to a diverse range of health applications including cancer treatment 16 depression 17 dermatology services 18 diabetes 19 and treatments for alzheimers disease 20 and weightloss programs 21 to date there has been limited application of dce methods to communitybased interventions for vulnerable youth such as the backtrack program in order to develop consensusbased methodological standards the international society for pharmacoeconomics and outcomes research developed a 10item checklist covering research question attributes and levels construction of tasks experimental design preference elicitation instrument design data collection statistical analyses results and conclusions and study presentation 22 this study follows these guidelines although the checklist does not endorse any specific methodological approach to conjoint analysis such as choice of attributes or analytical approach they do promote good research practices for the application of conjointanalysis methods for further discussion on methodological challenges inherent in conducting dces the reader is referred to additional sources 23 24 25 26 27 research question the research question for the current study is does the community prefer community programs like backtrack compared to greater police presence and what factors affect these preferences attributes and levels attributes and levels were identified using mixed methods researchers engaged in discussions with the research and backtrack program teams in order to characterise the choice decision identify the alternative programs and determine which factors might drive the decision process and which were most important given the tension between drawing a large sample from a regional area with a limited budget the choice was restricted to three intervention options each of which had two attributes and three levels of difference this simple design helps to ensure adequate power to detect differences between the key variables of interest program efficacy and cost an additional literature search informed the identification of realistic values for these variables 12 these measures led to a bestworst dce design with three labelled options current practice backtrack and greater police presence with two attributes each less crime and cost the current practice option had fixed levels of 0 less crime and aud 0 cost while the backtrack and greater police presence had three levels of 10 20 and 30 and aud 10 aud 20 and aud 40 for less crime and cost respectively these were initially arranged in a factorial design with each possible combination allowed which was then reduced to a more efficient design this design prohibited equal levels of one attribute across options eg 20 less crime for both backtrack and greater police presence and removed dominating scenarios eg where backtrack was aud 10 and 30 less crime while greater police presence was aud 40 and 10 less crime these dominating scenarios were defined by the research team this design was then tested in a pilot study of 43 participants to establish if the survey were easy to understand and complete and to determine a magnitude of difference between the three levels of effectiveness that would allow respondents to easily discriminate and tradeoff between percentage reductions in crime and cost it was found that current practice was only chosen as the best option 27 of the time and it was chosen as the worst option 906 of the time it was therefore removed for the final dce as it was clearly a redundant option furthermore it was found that peoples responses generally made sense in that higher costs and lower reductions in crime lead to a greater chance of selecting an option as best however the costs were too low to provide insight into the maximum value that people would be willing to pay for the final dce the levels of cost were therefore adjusted to aud 30 aud 60 and aud 120 based on model predictions from the pilot data the pilot data did show differences between the efficacy levels however the difference between 20 and 30 tended to reduce as the cost increased therefore the third level of efficacy was increased slightly for the final dce finally there were some comments regarding the clarity and wording of the attributes which led to the descriptions seen in table 1 table 1 provides the components used to construct the choice sets for the final dce construction of tasks each program type generated nine possible scenarios so the possible pairs numbered 81 choice sets with duplicate combinations of levels and with dominated scenarios were removed to minimise redundancy and maximise efficiency eighteen choice sets remained the minimum number of choice sets required to incorporate every possible tradeoff of the attributes and levels these were organised into two blocks with identical structure each containing half the choice sets the nine choice sets were then randomised within each block to minimise respondent burden participants were randomly allocated one of the two blocks experimental design the removal of duplicate levels and dominating scenarios to increase the amount of useful preference information resulted in a nonfactorial design across the two options of backtrack and greater police presence there were six possible pairs of efficacy and six of cost excluding duplicates eg 10 for both options a fully factorial design would then combine these six pairs with each other to produce 36 possible choice sets our design restricted the combinations of pairs such that an option could not have both a lower cost and greater percentage than the other option and thus a tradeoff needed to occur as seen in table 2 this resulted in each efficacy or cost pair occurring three times each across the 18 choice sets each combination of efficacy with cost did not occur equally however with lowerhigher costs more likely to occur with lowerhigher efficacy this can cause difficulties in interpreting marginal probabilities as it can appear that higher costs are preferred to lower costs however the cumulative link model used for analysis appropriately manages such a design preference elicitation preference elicitation was by tradeoff the respondent was asked to choose one option from the choice set no allowance for indifference was provided explanations about how to complete the task and cheap talk were included background information also provided context of crime within the local catchment area an example of the survey is provided in the supplementary material instrument design the dce utilised a survey for facetoface delivery demographic and clinical background information was collected so that characteristics of respondents could be examined and subgroup analyses could be performed and responder bias examined the survey included detailed descriptions on attributes and levels and an explanation of the decision scenario to provide good explanations in an attempt to inform participants the choice they were asked to make and how to complete the choice tasks data collection and setting data was collected over a 12day period between 30 may 2016 and 10 june 2016 by trained and experienced researchers data collection was scheduled at different times and days with researchers allocated to various locations to maximise reach in order to minimise the potential for selection and volunteer bias respondents were selected randomly by systematically counting passersby who were within the target age to a prespecified number and approaching the nth person the number of nonresponders or individuals approached who did not consent to participate in the dce was recorded to calculate the response rate this record included gender and approximate age within a range determined by the interviewer all researchers followed the same implementation protocol they began with an introduction to the research project to elicit informed consent from potential respondents in order to promote incentive compatibility respondents were informed that the results of the study were part of an economic analysis that would be used to inform policy each respondent was then shown a sample choice set to ensure they understood the dce survey format the respective program attributes and efficacy and cost levels as well as the task they were required to complete respondents were then asked to repeatedly choose between the two scenarios based on their efficacy and cost after completing the nine choice sets the respondents were given an additional separate question which asked if there was an intervention or option other than backtrack or greater police presence they would prefer if the answer was affirmative they were asked to explain their alternative this question was followed by six demographic questions designed to elicit factors that may be influencing choice such as gender age employment status education and income postcode was included to confirm that respondents were residents of the specified community catchment statistical analyses we used a cumulativeprobit link model because it provides a psychological interpretation of the choices in terms of a thurstonian or random utility model with normally distributed utility 28 the dce model excluded interventionspecific coefficients for cost and benefit and excluded an alternative specific constant the former specification was selected to facilitate ease of data collection and model interpretation which was judged to be a higher priority than optimising the precision of the estimate given this is the first economic modelling that has ever been applied to communitybased programs for highrisk young people internationally 12 the latter specification is appropriate given the aim of the study is to estimate preferences for existing approaches to reducing youth crime rather than predicting the likely adoption of new strategies 23 statistical analysis of the data used a cumulative link model an approach like logistic regression to appropriately treat the nonfactorial experimental design we assumed a probit link which also provides a psychological interpretation of the choices in terms of a thurstonian or random utility model with normally distributed utility we estimated a linear model on the mean of the utility distribution within the four factors of the design as predictors variance fixed arbitrarily at 1 and an estimated decision threshold parameter all analyses were conducted using r 29 results a total of 282 respondents who satisfied the inclusion criteria completed useable dce surveys a total of 805 people were approached a survey response rate of 35 women were more prevalent responders than men with slightly elevated numbers of female respondents in the 3049year age group ninety per cent of respondents were residents of armidale of the remaining 10 in the survey catchment 4 came from uralla and 25 from guyra the sample also comprised a variety of educational levels with almost half having completed a university education 42 of these with postgraduate qualifications only 14 of the sample had less than a year 12 level of education there was however a more even spread of employment types and incomes a total of 39 of respondents were in fulltime employment 26 had part time or casual employment and 29 were not in the workforce of the 79 of the sample who answered the income question 30 earned over aud 80000 per year and 27 earned aud 39000 or less forty per cent of respondents responded affirmatively to the optout alternative question half of the suggestions provided by these respondents related to youth programs like backtrack that addressed social needs employment needs educations needs or a combination of these eighteen per cent of respondents suggested family programs rather than youth programs 10 opted for a combination of greater police presence and backtrack and 8 for mental health support or rehabilitation the remainder suggested systemic policy level changes indigenous specific religion based or justicebased approaches the dce generated results that consistently demonstrated a preference for social programs to address youth crime and community safety in the armidale area overall the proportion of times in which respondents chose backtrack over greater police presence was very high 748 the estimate of the decision threshold was significantly below zero which reflects the strong tendency to favour backtrack over greater police presence in these data each of the four attributes had a statistically significant effect on the utility reflecting their importance to choose the standardised regression coefficients indicates the relative importance of the different attributes two coefficients were positive indicating that greater values of those attributes led to more people choosing backtrack over greater police presence and two coefficients were negative these directions are exactly as expected the effect on utility was greatest for backtrack benefit moderate for each of backtrack cost and police benefit and small for police cost this pattern indicates that respondents were mostly influenced by the benefit of backtrack for example adding one extra dollar to the cost of backtrack has the same influence as subtracting approximately three dollars from the cost of police estimated choice proportions from the probit regression are used to show how the different factors influence choice each of the four panels in the figure takes one of the factors and shows how the proportion of people choosing backtrack changes as this factor is increased the dashed red lines show the point of indifference 50 choice the top left panel shows that people more often choose backtrack than greater police presence until the cost of the backtrack option reaches approximately aud 150 the top right panel shows that people always choose backtrack more often than policing no matter what cost we gave to the police option the bottom left panel shows that backtrack is mostly preferred over policing even for very small benefits of the backtrack option the bottom right panel shows that respondents only choose policing more often than backtrack once the benefit of the police option exceeds about 53 analyses were rerun after splitting the data by gender and by education level and by household income for each subset the probit regression above was recalculated there were very small differences between the subsets men were more sensitive to cost than women and this was true for the cost of the backtrack program and the cost of greater police presence to make this concrete women found backtrack and police options equally attractive when the cost of backtrack was aud 196 but men found them equally attractive at a cost of only aud 130 people with tertiary education were more sensitive to all the factors than people with secondary education however this was not a reliable difference most likely due to the relatively small number of respondents who had secondary education analyses were rerun after splitting the data by gender and by education level and by household income for each subset the probit regression above was recalculated there were very small differences between the subsets men were more sensitive to cost than women and this was true for the cost of the backtrack program and the cost of greater police presence to make this concrete women found backtrack and police options equally attractive when the cost of backtrack was aud 196 but men found them equally attractive at a cost of only aud 130 people with tertiary education were more sensitive to all the factors than people with secondary education however this was not a reliable difference most likely due to the relatively small number of respondents who had secondary education discussion in a ruralregional community where there is concern about youth unemployment and associated youth crime and antisocial behaviour 30 public perception of a community program designed to address the needs of high risk young people has the potential to be a powerful determinant of program acceptability uptake success and sustainabil discussion in a ruralregional community where there is concern about youth unemployment and associated youth crime and antisocial behaviour 30 public perception of a community program designed to address the needs of high risk young people has the potential to be a powerful determinant of program acceptability uptake success and sustainability our reviews of the literature identified a lack of outcome evaluation studies of interventions that targeted multiple risk factors relative to single risk factors among highrisk young people 1 or economic evaluations of interventions for high risk young people 2 further very few studies have considered the viewpoint of the community itself or the value that they may attach to communitybased programs that address youth crime this research leverages off the implementation of the backtrack program implemented in armidale nsw since 2006 discrete choice experimental methodology was implemented to explore preferences for and value of implementing the backtrack program to reduce youth crime and improve community safety overall findings the results from this study showed that in a representative sample of the population of armidale there was strong preference for backtrack overall respondents chose backtrack over greater police presence 75 of the time and continued to choose backtrack to a cost of aud 150 per household per year equivalent to a total benefit of aud 204 million per annum the effectiveness of backtrack was the strongest predictor of choice however all four attributes or predictors had a statistically significant effect on utility the direction of the effect of the four attributes on utility was as expected for example greater backtrack benefit and greater police cost resulted in respondents choosing backtrack over greater police presence whereas greater backtrack cost and greater police benefit had a negative effect on the choice of backtrack over greater police presence split sample analyses conducted to account for differences in preferences that arise from differences in individual characteristics such income education and gender revealed no significant differences between the subsets analysed these results provide further evidence of the strong community support for backtrack interestingly when respondents were given the option of suggesting an alternative program to the two offered in the dce most suggestions were similar socialeducationhealth programs or a combination of greater police presence and backtrack this research fills a void in the literature in terms of understanding community values and preferences for programs like backtrack such information is important in the context of program uptake funding and sustainability the research methods also extend the application of dce methods and provide important inputs into economic evaluations by valuing community benefit the armidale community has embraced the backtrack program and graduates of the backtrack program are seen as important community members 4 this is in stark contrast to community attitudes of participants first enrolling in the program that have a legacy of crime and community disruption limitations data collection was somewhat limited by time and funding constraints however a sample size of 282 was considered adequate for the purposes of the analysis this study removed the optout alternative because it was judged to be the worst alternative by 90 of respondents excluding choicespairs in a labelled dce needs great care because of relatively subjective judgements about the threshold for what proportion of responses ought to be properly regarded as a marginal result and because retaining more alternatives can be used to help more precisely understand the outcomes in this study for example we have estimated respondents willingness to pay for different interventions but retaining more alternatives could have also helped determine whether respondents made their choices because of their preferences related to the effectiveness of each alternative or the type of intervention future research could start to examine the decisionmaking process of respondents in determining their preferences in addition to identifying their preferences per se we used a cumulativeprobit link model because it provides a psychological interpretation of the choices in terms of a thurstonian or random utility model with normally distributed utility 28 although the cumulativeprobit model was selected because of its choice and technical features were appropriate a mixed model could have been used to demonstrate the distribution of preferences across the population future research could utilise both approaches to quantitatively examine the robustness of the results to the choice of model and analysis the key design features of this study were the exclusion of interventionspecific coefficients for cost and benefit and the exclusion of an alternative specific constant having a costspecific coefficient would allow a more precise estimation of wtp and should be integrated into future dce evaluations of programs for highrisk young people although the inclusion of an alternative specific constant is generally recommended in dces to avoid forced choices the decision to exclude it in this study was appropriate for two reasons first neither of the alternatives under consideration were new services in the community meaning that respondents were asked to choose between realistic existing alternatives rather than more abstract experimental options for which an optout option would be appropriate second the way in which an optout alternative could have been presented to respondents would have been arbitrary and of unknown impact on respondents choices 23 a further methodological issue is that the extent to which the results can be reasonably extrapolated to the whole community might be limited by two factors first this dce only considered one alternative to more policing rather than multiple alternative options such as harsher penalties for offending or increasing youth detention the extent to which the community would preference backtrack over alternatives other than more policing across the entire population of the community remains unclear second is the extent to which the sample was representative of the population a response rate of 35 was lower than expected but given the unfamiliar nature of a dce survey and the potential for respondent burden was an acceptable outcome the survey results showed that the dce captured a representative sample of the population of the armidale region 31 the largest proportion of nonresponders were women in the 3049year age group a group who tended to be apologetic citing lack of time being at work busy with children or going to collect children as their reasons for not participating conclusions this study estimates a strong community preference for backtrack relative to more policing although it is a compelling result the exact strength of the estimated preference may lack some precision as a consequence of the methods nevertheless the apparent strong preference for communitybased programs to reduce youth crime relative to more policing coupled with the new availability of refined dce methods 2327 highlights the clear value of replicating this dce with more communitybased programs for highrisk young people although the backtrack program commenced in armidale the program has been implemented in several other rural communities the backtrack strategy is to build capacity and capability to positively impact the lives of many more young people across a range of disparate communities building an evidence base for programs like backtrack are essential for ongoing investment and sustainability this research adds to this evidence base by highlighting strong community preferences for youth based programs that are community based rather than traditional means of dealing with youth crime through punitive measures supplementary materials the supplementary materials are available online at comarticle103390ijerph18105097s1 informed consent statement informed consent was obtained from all clients involved in the surveys data availability statement no restrictions apply to the availability of these data and are available from the corresponding author conflicts of interest cd lw sb ke and as declare no conflict of interest author as is the brother of bernie shakeshaft who is the founding manager of backtrack and was manager of the program during the period of this research

backtrack is a multicomponent communitybased intervention designed to build capacity amongst 1417yearold high risk young people the aim of the current study seeks to explore community value and preferences for reducing youth crime and improving community safety using backtrack in a rural setting in armidale new south wales australia the study design used discrete choice experiments dces designed in accordance with the 10item checklist outlined by the international society for pharmacoeconomics and outcomes research the dce was pilot tested on 43 participants to test feasibility and comprehension a revised version of the survey was subsequently completed by 282 people over a 12day period between 30 may 2016 and 10 june 2016 representing a survey response rate of 35 ninety per cent of respondents were residents of armidale the local rural town where backtrack was implemented the dce generated results that consistently demonstrated a preference for social programs to address youth crime and community safety in the armidale area respondents chose backtrack over greater police presence 75 of the time with an annual benefit of australian dollars aud 150 per household equivalent to a community benefit of aud 204 million this study estimates a strong community preference for backtrack relative to more policing a community willing to pay equivalent to aud 204 million highlighting the clear value of including community preferences when evaluating communitybased programs for highrisk young people

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introduction social entrepreneurship is a new emerging field challenged by competing definitions and conceptual frameworks gaps in the research literature and limited empirical data a number of scholars argue that entrepreneurship is a process that can be applied to the creation of economic or social ends for example drucker suggested that the entrepreneur always searches for change responds to it and exploits it as an opportunity regardless of whether that opportunity is commercial or social in nature often however the focus in entrepreneurship studies is on only forprofit activities while the term social entrepreneurship has focused primarily on activities with social purposes in recent years the term social entrepreneurship has emerged to describe the application of entrepreneurial activities with an embedded social purpose for our purposes business entrepreneurship focuses on wealth creation and is of interest because of its potential to fuel economic development whereas social entrepreneurship focuses on making the world a better place and creating social capital recently the discourse on social entrepreneurship has been fuelled by a number of high profile business entrepreneurs who have turned their attention to social causes in 2006 bill drayton founder of ashoka said social entrepreneurship is helping to bring about a productivity miracle in … the citizen half of the world draytons concept has attracted some wealthy and influential proponents including billionaire jeff skoll who created the skoll foundation an organization devoted to promoting social entrepreneurship skoll describes social entrepreneurs as individuals motivated by altruism and a profound desire to promote the growth of equitable civil societies who pioneer innovative effective sustainable approaches to meet the needs of the marginalized the disadvantaged and the disenfranchised social entrepreneurs are the wellspring of a better future this concept of social entrepreneurship has also been popularized by books including david bornsteins how to change the world social entrepreneurs and the power of new ideas it has also been popularized by the business press for example the economist has heralded the rise of the social entrepreneur while the popular press has waxed enthusiastically about this new phenomenon researchers have attempted to examine conceptualize and categorize entrepreneurship and social entrepreneurship despite the excitement dees and anderson observe that as an academic field social entrepreneurship is still immature and lacks the deep rich explanatory or prescriptive theories expected in a more mature academic field perhaps more importantly nicholls observes that innovative social ventures cannot achieve their full potential until there is a more comprehensive understanding of how they are driven and what assumptions motivate them however even in the social entrepreneurship literature debates over definition persist for example brock steinder and kim conducted a review revealing more than a dozen different definitions for social entrepreneurs and social entrepreneurship the social entrepreneur should be understood as someone who targets an unfortunate but stable equilibrium that causes the neglect marginalization or suffering of a segment of humanity who brings to bear on this situation his or her inspiration direct action creativity courage and fortitude and who aims for and ultimately affects the establishment of a new stable equilibrium that secures permanent benefit for the targeted group and society at large pbs the new heroes a social entrepreneur identifies and solves social problems on a large scale just as business entrepreneurs create and transform whole industries social entrepreneurs act as the change agents for society seizing opportunities others miss in order to improve systems invent and disseminate new approaches and advance sustainable solutions that create social value schwab foundation what is a social entrepreneur a pragmatic visionary who achieves large scale systemic and sustainable social change through a new invention a different approach a more rigorous application of known technologies or strategies or a combination of these skoll foundation the social entrepreneur as societys change agent a pioneer of innovation that benefits humanity social entrepreneurs are ambitious mission driven strategic resourceful and results oriented thompson 2002 people with the qualities and behaviours we associate with the business entrepreneur but who operate in the community and are more concerned with caring and helping than making money reinforcing the need for a more constrained definition a recent study by the center for the advancement of social entrepreneurship suggested the need to clarify definitions currently fragmenting the academic community and to find terminology that can be used to distinguish more easily between different forms of socially entrepreneurial behaviour author in addition to definitional issues the area of social entrepreneurship is currently disadvantaged by the limited empirical evidence available as case acknowledges current success stories while powerful and moving lack hard data or proven measures of success scalability and sustainability otherwise this could look like a field with lots of little ventures that are admirable but almost never come close to the espoused goal of widespread lasting impact and that never match up to the problems they are designed to solve specifically there is a lack of robust data directly linking social entrepreneurship with social improvements indeed some authors have even suggested that the proliferation of new organizations may actually create competition and inefficiency within an already highly fragmented social sector finally in addition to documenting success it has been noted that there is also a need to understand failures our paper is structured as follows first we discuss aspects of the literature that we deem relevant to issues related to definition as well as levels of analysis next we discuss our research questions and methods for citation and content analysis including the selection of texts categories of analysis and our coding approach we then present our findings in terms of overall patterns in the literature finally we close with a discussion of our conclusions and the possible implications to both research and practice categorizations of social entrepreneurship social innovation versus social enterprise in recent years a considerable amount of research has focused on debating what is included or excluded in the definition of social entrepreneurship overall although the definitions may vary there is general consensus that there should be two parts to the definition of social entrepreneurship first social entrepreneurship involves creating something new characterized by innovation rather than simply the replication of existing enterprises or practices this newness may take the form of a new approach or new process second at least some of the objectives of the undertaking need to be related to creating social value sometimes referred to as social good rather than simply creating personal and shareholder wealth both parts of the definition represent challenges first delimiting the nature and extent of the innovation is somewhat problematic and highly subjective second the definition of social value can be contested our research shows that there is little consistency in the analyses that lead to categorizing some individuals and organizations as social entrepreneurs and others as philanthropists nonprofits ngos or activists some including dees and anderson the center for the advancement of social entrepreneurship andneck bush andallen argue for a big tent approach to social entrepreneurship that embraces a wide range of activities and organizations some scholars even portray social entrepreneurship as an innovative social valuecreating activity that can occur within or across the nonprofit business and public sectors however other authors insist on a narrower definition for social entrepreneurship for example yujuico suggests that established institutions such as government agencies aid agencies charities foundations and nongovernment organizations should not be included as social enterprises because they straddle the divide between forprofit and nonprofit institutions in terms of goals and means and because their goals of enhancing social wellbeing are similar to those of nonprofit institutions but these enterprises are not primarily funded by revenues from tax collection or charitable aid and are thus less insulated from market dynamics boschee mcclurg for example maintain that unless a nonprofit organization is generating earned revenue from its activities it is not acting in an entrepreneurial manner such approaches tend to have a probusiness bias using business as a leverage to improve social conditions martin osberg insist that the field must be restricted to exclude social service provisions or social activism in order to gain respect among serious thinkers they tend to focus on a narrower notion of social enterprise in which profit is earned to advance social objectives whether by forprofit nonprofit or publicprivate partnership dees anderson suggest that these two competing conceptions represent two schools of thought which they term the social innovation school and the social enterprise school the authors suggest that crossfertilization rather than competition between these perspectives will enrich the overall field of social entrepreneurship forms of organization the first question for our content analysis relates to the question of the scope and the focus of the activity as described on a continuum from purely income generating to purely social goals another dimension of the categorization of social entrepreneurship concerns organizational forms which seem to operate along a continuum including 1 businesses or business people engaging in social goals 2 crosssectoral partnerships including forprofit and nonprofit organizations 3 shifts by nonprofits to new sources of funding or 4 new processes to alleviate social problems and catalyse social transformation thus we also focused our analysis on three organizational formsprivate sector firms engaged in achieving social goals privatepublic partnerships or organizations whose main focus is purely social goals levels of analysis to further complicate definitional matters social entrepreneurship research can be categorized by the level of analysis writing about entrepreneurship jennings distinguishes between research focused on the individual characteristics of entrepreneurs organizationalcorporate entrepreneurship processes and a third approach grounded in broad macro economic theory these levels of analysis may be differentiated as micro meso and macro micro level research at the micro level currently dominates the larger field of entrepreneurship research research in this stream mostly focuses on the entrepreneur examining entrepreneurship from a psychological and sociological perspective studies tend to focus on the characteristics of individual entrepreneursthe great man theory of innovationand use a variety of techniques to assess demographic and psychographic factors as well as other characteristics this approach has been adapted in studies on social entrepreneurs focusing on their individual traits and leadership for example the personal nature of leadership in socially entrepreneurial ventures may be more than beneficial it may be necessary mumford notes that social innovation involves certain cognitive operations and expertise not always seen in other forms of creative thought leaders must for example identify social restrictions on potential solutions and analyse the downstream consequences of social implementation as they generate revise and develop new ideas the characteristics attributed or discussed in relation to social entrepreneurs including public sector entrepreneurs parallel those associated with business entrepreneurs including leadership and charisma risk perceptiontolerance motivation personal attributes family issues and marginalization some research focuses on the motivation of the individual social entrepreneurs for example anderson and yujuico both suggest that social entrepreneurs are not only motivated by altruism but also outrage and resentment at injustice this focus on the new heroes celebrated by ashoka is grounded in theories which ascribe significant agency to individuals in effecting change most of the definitions provided by brock et al for example focus on the character of the individual social entrepreneur it must be noted however that some authors find the focus on the individual to be elitist meso level at this level the research focus is on entrepreneurial organizational processes as ways to foster innovation focusing on the process of entrepreneurship a number of researchers identify factors common among entrepreneurial enterprises such as focussing on opportunities not resources this research tends to focus on the processes for achieving social goals including analyses of organizational forms goals and structure governance and management issues stages in the social entrepreneurship process and new approaches to public sector management further the process of social entrepreneurship has been described in a way that parallels discussion of entrepreneurship processes namely identify a gap and related opportunity inject imagination and vision into the solution recruit and motivate others to the cause and build essential networks secure the resources needed and introduce proper systems for controlling the venture macro level research at this level focuses on entrepreneurship as part of economic and social development at the macro level there are studies that attempt to understand the broad structural cultural and economic forces which shape entrepreneurship such as neoliberalism some of these forces have the objective of driving government policies such as tax policies regulatory frameworks and education that in turn drive or promote entrepreneurship leading work which focuses on the macro level includes the global entrepreneurship model which considers the economic context and complementary activity among different groups studies looking at the complex relationship among entrepreneurship large firms and macroeconomic activity including the notion of embeddedness analyses of government policies and access to financing and the impact of catalyst enterprises on the economy more recently we see similar macro efforts to conceptualize social entrepreneurship within the broader environment for example weerawardena sullivanmort consider its iterative relationship with social development including peace and human rights they discuss the stages of development of a civil society as well as interactions among movements and groups while considering other contextual factors such as politics communications and social infrastructures finally there are also studies which consider the interaction among these levels for example mair marti suggest that social entrepreneurship needs to be understood as a process resulting from the continuous interaction between social entrepreneurs and the context within which they and their activities are embedded in turn linking the individual the process and the context our study in a modest effort to contribute to the social entrepreneurship landscape we address the following specific research questions what are the patterns in the academic literature on entrepreneurship social entrepreneurship social movements and social marketing how can literature on social entrepreneurship be categorized in terms of objectives research methods and levels of focus what empirical evidence and specifically case studies have been examined under the umbrella of social entrepreneurship how do these cases fit with the categories of social entrepreneurship including dimensions such as goals sectors organizational forms and levels of analysis how have these cases been framed by other disciplines methodology our paper used a combination of textual analysis techniques to examine overall patterns in the discourse on entrepreneurship and social entrepreneurship identify empirical studies and explore the discourse in further detail the first stage in the analysis involved using standardized search terms to identify and collect empirical articles on the topic of social entrepreneurship standardized searches were conducted in all of the databases within proquest and ebscohost respectively as well as google scholar the searches were not restricted by date but were limited to their occurrence in the citation and abstract of scholarly journals in the proquest databases and in the title of the article for ebscohost databases and google scholar in which it was not possible to restrict to the abstract the search term social entrepreneur or social entrepreneurship was entered into the database to identify all articles containing these terms we then analysed the patterns of these over time and contrasted them with identical searches on the terms entrepreneur or entrepreneurship social movement and social marketing it should be noted that combining searches from multiple databases presents significant problems as there are duplicates and google scholar searches include citations as well as complete articles notwithstanding as the patterns in the searches of individual databases were similar we believe the results are a reasonable indication of trends and comparisons among subjects but not of total scholarly production in journals the number of citations per year were recorded from the beginning to the end of the years in which they began to emerge we then tallied the numbers across the three search engines and graphed the pattern of citations that emerged for the search social entrepreneur or social entrepreneurship which we planned to code results were exported into a bibliographic management program refworks which allowed us to view and subsequently eliminate all duplicates all results not in english and all results that were not scholarly journals but not filtered by the respective databases after these items were removed we were left with a final master list of 567 unique articles citing social entrepreneur or social entrepreneurship these 567 articles were universitys journal subscription service and thus were not accessible for review the remaining 523 articles were then ascribed a code and hand sorted by four independent coders for occurrences of references to specific cases of social entrepreneurship upon closer examination approximately threenot make reference to specific cases of social entrepreneurship at the conclusion of the aforementioned process a final total of 123 articles were selected for coding and detailed analysis each individual coder was provided with a standardized coding sheet to record information on each article and each case study respectively the coding sheet consisted of the following items the individual entrepreneur named gender of the individual studied 3 location of the case studied organization name sector of the organization including health economic development education equality seeking violence prevention service provision and other 6 the objective of the organization namely income generating for social goals purely social goals or a combination of income generating and social goals all cases were coded twice and the results were tabulated and analysed to ensure internal consistency an overall total of 366 mentions of 274 unique cases were identified findings citation analysis we found the first citation of social entrepreneurship in 1984 for the period 19862007 our search in all proquest databases produced 162 articles and our search in all ebsco host databases produced a total of 60 articles the search in google scholar produced 2186 1 results for a total of 2728 citations over 21 years on social entrepreneurship peaking with 433 citations in 2006 graph 1 citation analysis social entrepreneur or social entrepreneurship in contrast the terms entrepreneur and entrepreneurship produced citations back to the 1970s with a total of 201005 citations over 21 years peaking with 19171 citations in 2006 this indicates that social entrepreneurship is a tiny fraction of the overall body of literature on entrepreneurship graph 2 citation analysis entrepreneur or entrepreneurship with 56540 citations over 21 years the social movement citations peak in 2004 with 2996 citations this represents more than 20 times the citations we found for social entrepreneurship or social entrepreneur graph 3 citation analysis social movement journal of strategic innovation andsustainability vol 7 2011 107 the term social marketing produced 1384 citations over 21 years peaking in 2007 with 1785 citations the term first appears in the literature in the 1960s graph 4 citation analysis social marketing content analysis we reviewed 567 unique articles and identified 123 articles which made reference to case studies we analysed the 123 articles in more detail and found a total of 366 cases studies cited within the way in which they were cited varied from a passing mention for example vega and kidwells classification of 80 cases of entrepreneurship including social entrepreneurship to detailed assessments such as alvord brown and letts comprehensive study of cases of social entrepreneurship further analysis of these showed that only 35 of the 366 cases were cited in more than one article the rest were mentioned only once in one article the 10 cases most often cited were grameen bank bangladesh rural advancement committee ashoka ben and jerrys partnership for a drugfree america delancey street foundation and pioneer human services in about 52 percent of the total cases male a female of the organizations cited as examples of those engaged in social entrepreneurship more than one organizations referred to in the total nu and lesbian these findings are shown in figure 5 below figure 1 primary objectives in cited cases of social entrepreneurship of the organizations discussed their objectives were split relatively evenly across the three categories we identified those identified as having income generation for social goals as the primary objective entified as having primarily social goals accounted for 224 als accounted for 202 in terms of the impact of social entrepreneurship examples we found only 28 articles which provided detail on specific outcomes however very few of these included what would normally be considered to be empirical analysis of the results almost none defined criteria for success and systematically applied them most had very limited measures of performance discussion an emerging field definitions our analysis of case studies reflected many different definitions of social entrepreneurship some examined businesses or business people engaged in crosssectoral partnerships with social objectives efforts by nonprofits to secure new sources of funding or projects with objectives related to social services education health environment and social justiceequality seeking however there were fewer cases which illustrated the development of a process to alleviate social problems and catalyse social transformation that did not have a commercial aspect our study raises some interesting questions about how and why individuals and organizations are classified as social entrepreneurs and more importantly why others in the same sector are not for example the sierra club is referred to as an example of social entrepreneurship but greenpeace is not robert redford is cited as an example of a social entrepreneur for his work on the sundance film festival but other filmmakers promoting social change are not in some cases the social entrepreneur is simply a social entrepreneurship literature which made any reference at all to social movements these scholars reference the larger context of government downloading and shifts to corporatization in framing social entrepreneurship while using the lens of innovation processes and entrepreneurship is a relatively new approach in management disciplines there is a long history in political science of studying advocacy groups and social movements in a way social entrepreneurship is simply a reframing of phenomena which have been the subject of research in other disciplines moreover there is overlap with the literature on social marketing which has been used for example to examine the evolution of many innovations related to health promotion from antismoking to injury prevention and aids awareness more interdisciplinary work is warranted gender the fact that almost 40 of the social entrepreneurs identified were female has far reaching implications which need to be further explored the gender imbalance in forprofit entrepreneurs has been widely discussed as scholars have noted among successful business owners there are significant gender differences in the definition of success but not necessarily differences in entrepreneurial self efficacy or ability consequently efforts to restrict the definition of social entrepreneurship to the narrower notion of social enterprise may have the unintended consequence of excluding women as they are more prominent in cases related to social innovation this should be examined further conclusions and implications social entrepreneurship broadly defined poses more challenges to definition and impact assessment than business entrepreneurship for example the definition of success for business entrepreneurs is less complex than the definition of success for social entrepreneurs social entrepreneurship literature is laden with questions about evaluating outcomes and defining success while there are established definitions of corporate success it is more difficult to define success in social entrepreneurship some define success as being the generation of social goods however this does not clarify the definition of social entrepreneurship success since one persons definition of a social good may be anothers definition of a social evil for example birth control or gay rights more work is also needed on the criteria to define the objectives of social entrepreneurs and the nature and magnitude of impact while some suggest that a social entrepreneur must effect lasting structural change this is a standard seldom applied to successful business entrepreneurs at the same time we need a clearer definition of newness and ways to demonstrate it our study reinforces findings made in previous research about gaps in the social entrepreneurship literature particularly concerning the significant need for more empirical research in the field our findings also suggest that perhaps because of definitional debates there is comparatively limited attention focused on innovations with purely social objectives even though we argue that these should fall into the definition of social entrepreneurship in largely ignoring case studies from the social movement literature the social entrepreneurship literature misses some opportunities to build theory and also to explore interesting models from other disciplines to address this we favour the broader definition of social entrepreneurship advanced by the social innovation school but we also see value in not choosing one definitional school over another we also maintain that there is still a need to define success in social entrepreneurship and in doing so to first define social good while social value is not as clearly defined as profit there is some global consensus on the common good as reflected in such agreements as the universal declaration on human rights and the united nations millennium goals the absence of consistent frameworks and rigorous empirical research makes it difficult to promote critical perspectives and debates on the specific phenomena categorized as entrepreneurship social entrepreneurship social movement or social enterprise there continues to be opportunities to do more empirical research to evaluate successes and failures and ultimately to harness best practices finally there does not seem to be consensus on the criteria or its application regarding when and why some individuals and organizations are framed as examples of social entrepreneurship while others are not for example if ducks unlimited is classified as an example of social entrepreneurship is the national rifle association if susan b anthony is a social entrepreneur are other leaders of the suffragette or womens movement if bill and melinda gates are social entrepreneurs why is there no mention of george soros how do we explain who is in and who is out what are the boundaries and criteria our research reinforces some of the suggestions made in previous research about gaps in the social entrepreneurship literature particularly concerning the significant need for more empirical research in the field and more rigor in the application of definitions to move forward it will be important to recognize the impact of ideological framing and bias which may limit analysis endnotes the absence of an agreed upon overarching conceptual framework for defining social entrepreneurship combined with the lack of empirical research makes it difficult to define success undertake comparisons evaluate outcomes and suggest best practices this discrepancy also reinforces questions that have previously been raised about the challenges of evaluating outcomes and defining success for example most of the papers published to date have been theoretical and have advanced claims and assertions about social entrepreneurship based on selected anecdotal examples generally researchers present selected case studies to illustrate preferred theories rather than developing theories from these case studies very few provide any primary research social entrepreneurship versus social movements there is also evidence to suggest that social entrepreneurship particularly the stream focused on social innovation is simply a reframing of a phenomenon previously labelled in other ways many of the cases cited in our research as examples of social entrepreneurship such as the sierra club are defined elsewhere as social movements the social movement literature which is extensive is full of examples of innovations which could also arguably be examined through the lens of social entrepreneurship yet this literature is seldom cited in studies of social entrepreneurship the social movement process described by mcadam mccarthy zald parallels other innovation processes and includes the following steps define policy goals frame the issue recognize and exploit opportunity and mobilize resources in table 3 we identify a few of the cases we found which are framed as examples of social entrepreneurship but are also discussed in the social movement literature with no crossreferencing this would be a fertile area for further exploration research on social movements and social change tends to place more emphasis on large scale structural forces at the macro level with individuals acting as catalysts to more or less effectively apply organizational and advocacy processes the social marketinghealth promotion communication and action research literatures focus on planned interventions and processes many of which would also fall into the broad definition of social entrepreneurship we found few articles in the

competing definitions and limited empirical research are impediments to the emerging field of social entrepreneurship our study provides a systematic review of the literature and empirical materials used a standardized search of academic databases and citation analyses revealed trends in the literature content analysis was applied to a total of 567 unique articles from 1987 to 2008 revealing patterns in the research a total of 274 unique case studies or examples were cited in 123 articles and we analysed their characteristics generally we found very little empirical data on the topic confirming the need for more rigorous empirical research

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to gain traction in official policy making such as reported in jeanes et al this strengthening of focus in policy making could reflect the fact that participation in informal sport is said to be in decline therefore as we point out in this article there is a need to investigate where people engage in pa to establish the demand in urban locations we use socialmedia data coming from public geotagged twitter messages meaning that the location attribute is already attached to the messages our main analysis focuses on key words related to crosscountry skiing and is geographically limited to the helsinki metropolitan area in southern finland the secondary analysis concerns other sporting activity in the same locations as in the skiing tweets the hma comprises the cities of helsinki vantaa and espoo and the town of kauniainen these four areas combined constitute the largest urban concentration in finland it is not a typical urban area in that it contains many urban green spaces and urban blue spaces that are suitable for pa additionally the majority of finnish cities are designed to allow everyone access to places where they can engage in pa regardless of whether or not they like to do so outdoors our main research question is how can geotagged twitter tweets detect informal pa spaces and our subquestion is in what type of urban public space do people engage with in their informal pa we split the tweet analysis by skiing related key words in both english and finnish whereby skiing in finland means crosscountry skiing but can also include downhill skiing if done at a physical facility skiing in the hma is an interesting research topic because even though it is an urban environment there are numerous opportunities for skiing in public green blue and even street pa spaces we extend the analysis by comparing the skiing tweets to other sporting tweets within the same location to find out what sports people engage in when there is no snow the literature on informal participation in sport focuses on the improvement of overall health and wellbeing we do not separate the terms sport exercise and participation here because in our view any type of pa is beneficial in terms of having an active and healthy lifestyle in the city we therefore use the term physical activity from here on following the world health organization definition physical activity refers to all movement including during leisure time for transport to get to and from places or as part of a persons work children in finland are encouraged to engage in outdoor play from a young age going outside in all weathers while at kindergarten furthermore our case study area the hma has many outdoor play parks averaging almost one per neighborhood which is not the norm in many other countries these parks promote exercise in natural environments whilst honing childrens independent mobility through to adulthood however even though finns seem to have an ingrained habit of engaging in pa yearround around 70 of the adult population are not reaching the recommended weekly target of ≥150 min activity of moderatetovigorousintensity pa kolu et al point out the economic burden of a sedentary lifestyle in finland the total cost of low pa behavior came to approximately € 32 billion in 2017 and the costs attributable to high sedentary behavior totaled around € 15 billion according to the finnish institute for health and welfare around 70 of men and 60 of women in finland are overweight meaning that they have a body mass index of 25 or more and a third of the population are obese having a bmi of 30 or more a score of 185249 is healthy it was found in a similar recent study conducted by the helsinki and uusimaa hospital district that the annual healthcare costs for an obese person were approximately € 2665 rose et al in turn reported that spending two or more hours outdoors helps to prevent children from becoming short sighted in the near future which also eases the burden on health care therefore the provision of free public spaces that allow the population to be active outdoors is one among many simple and effective ways of improving health and simultaneously lowering the negative costs attached to being inactive it is suggested in current literature based on pa rates and the impact of the covid19 pandemic that there is a general tendency to be less active however according to the ministry of the environment there is a strategy to increase the recreational use of natural habitats in finland as part of prime minister sanna marins government program survey results have shown that in fact the covid19 pandemic increased the motivation of finns to exercise in local naturebased surroundings whereby almost everyone enjoys outdoor activities this adds to the relevance of our article researchers have found it difficult to establish participation rates for informal lifestyle sport pa of this type does not typically go on in a fixed place such as a physical sports facility hence usual practices such as counting tickets are not possible consequently for this article we focused our analysis on already geolocated twitter tweets to detect the demand for informal sport by location meaning that the pa takes place in an informal setting away from physical sports facilities it should be borne in mind that not all pa takes place by or in green or blue urban spaces and that street spaces also exist finland has a national database of sports facilities which also includes informal sports infrastructure comprising street spaces such as outdoor tabletennis tables and basketball courts we therefore distinguish between three informal urban pa spaces which are also land cover types green blue and street background defining informal spaces for physical activity for the purpose of this article we focus on informal pa spaces given that finland already has a national open database of sports facilities and their conditions namely lipas user demand for formal pa facilities can be tracked by means of ticket purchases or by scanning sports cards but this is not the case for informal spaces hence it is more difficult to estimate user demand in each location references informal sport definition mentions location coakley informal games exist when young people come together and agree to organize themselves for the sake of having fun and maximizing action kokolakakis et al the distinction between formal and informal definition is based on the frequency and context of participationformal sport implies doing sport in a club or through organized competition n n wheaton and oloughlin a defining feature of lifestyle sports is their selforganized and spontaneous nature with participation in predominantly informal settings often without external regulation or institutionalization y deelen et al typical informal and flexible sports settings are commercial health centers and gyms with informal groups and individual participation in the public space all of which make participants less dependent on formal structures such as membership obligations opening hours and the availability of specific sports facilities y jeanes et al traditional recognized sporting forms played by groups who are not affiliated to sporting bodies or pay membership fees n mathisen et al informal sports do not require adolescents to be part of organized official sports clubs but may involve high levels of leisure time vigorous pa n sports and whether they mention the location of the pa we use the term sport rather than physical activity because the majority of literature refers to informal sport the assumption being that participation is informal however as deelen et al point out participation in sport may be within sport clubs gyms or public spaces with a focus on the settings in which the sporting activity is located the authors also suggest that most informal sport goes on in public spaces and natural environments and we follow this same distinction in our case this even applies to downhill skiing slopes which have specific opening times and require entrance tickets but are still classed as informal because the public can choose what time to visit within the specified period therefore even though there is no fixed definition of informal sport it typically simply means being selforganized according to coakley for example formal sport is rulecentered and informal sport is actioncentered whereby the latter relies on group decisionmaking among the participants to be selfsustaining however this definition omits individual sports one variation is that the difference is simply a matter of the frequency and context of participation whereby formal sport takes place at regular times requires club membership and involves taking part in organized games and competitions on the grounds that the distinction between formal and informal sport is not yet fully adopted in either government or nongovernment agencies jeanes et al define formal sports as any activities that take place in affiliated sports clubs and within official sports structures for which participants pay a fee and compete in leagues they further define informal sports as any traditional sporting activity such as cricket football or basketball whereby participants do not pay membership fees and play in places such as local parks or community spaces they omit sports such as surfing skateboarding and parkour which they refer to as a lifestyle or leisure sport that evolved from resistance to traditional sport according to mathisen et al club sport increased in finland from 1992 to 2010 and general pa participation expanded with the introduction of new informal sports such as cross fit hiking and skateboarding we focus here on the location of the informal sporting activity which seems to have been omitted in existing definitions interpreting green blue and street urban spaces green and blue urban spaces have been gaining traction in academic literature it is becoming increasingly common to study how and where people exercise in a city locations in which physical activities take place that are scenic and in natural surroundings tend to motivate people to improve their overall wellbeing finland is a suitable country in which to conduct research on where people engage in pa given the large amount of land used as green and blue spaces green areas specifically forests comprise more than 75 of the countrys land blue spaces namely water bodies are particularly high in recreational value among finnish citizens inland water bodies such as lakes and rivers cover ∼10 of the countrys total surface area accounting for 34539 km 2 these two statistics exemplify the suitability of finland for studying where people exercise outdoors in nature as even urban spaces are encompassed by both green and blue spaces according to a survey of around 1250 residents of helsinki and tampere conducted by the finnish forest research institute over 80 of them thought that the green spaces improved their residential area and over 90 said their favorite place was in nature in a forest on a shore or in another type of green space this has led to the term green exercise which has recently arisen to emphasize the positive effects of combining pa and exposure to nature it also has an effect on peoples emotions particularly when walking or otherwise exercising in a forest environment having included three different types of informal urban space in this article namely green blue and street we thought it important to understand how others used these terms and what in particular made the pa informal compared with traditional or formal sports we now turn to our third and final urban space namely street space streetbased sports have in the recent past been associated with rebellion against more traditional informal sport encompassing skateboarding or parkour we define street space pa here as any physical activity that does not take place on or around green or blue space but on asphalt concrete or similar hard surfaces including those on which outdoor open sports parks are built outdoor public spaces in finland have varying uses depending on the season gravel parks for example are used in summer for boules and football and in winter for ice skating there are 943 street workout parks in finland of which 326 are within the hma and there are many more outdoor street pa opportunities ranging from obstacle courses to frisbee golf and workout step hills indoor public sport facilities were forced to close to the public during the winter of 20202021 due to the covid19 pandemic and only outdoor public spaces were allowed to remain open thus even under the heavy restrictions related to the pandemic there were still many outdoorexercise opportunities that allowed the general public to remain active recent research has focused on the impact of the covid19 pandemic and the resulting increasingly sedentary lifestyles among the population there was still access to green space in helsinki and as korpilo et al found in fact some forest areas nearby were overcrowded which had a negative impact upon the environment informal sport is not often explicitly mentioned in policies in finland for example the sports for all policy is still centered around organized sports focusing on diversity it would therefore be useful to know where in urban spaces people are doing their pa urban spaces tend to be associated with a decreasing amount of green space and with discouraging people from exercising which could fuel an increase in sedentary living our focus here however is on how urban areas could still give access to a variety of outdoor sports a healthy city as defined in the zagreb declaration is one that provides conditions and opportunities that encourage enable and support healthy lifestyles for people of all social groups and ages li et al conducted a review to distinguish any differences between green and nongreen exercise they found that green exercise did in fact have psychological advantages since then social media has been used as a novel source of data to capture the usage of green space during the covid19 pandemic however these studies omit other urban spaces in which informal pa takes place outdoors in fixed locations such as outdoor gyms skate parks and tabletennis facilities moreover outdoor informal sports such as cycling kayaking and walking do not take place in fixed locations it would therefore be useful for municipalities to know where their populations were engaging in pa previous usage of geotagged twitter tweets geotagged twitter messages have been successfully used in previous academic studies spanning many research topics such as for analyzing political events or human mobility huang and carley refer to twitter as a useful proxy for understanding peoples mobility and social events tweets are naturally occurring data the main purpose of which is not for analysis this makes it potentially more suitable for further analysis given that data collected from online users as a byproduct are said to be more reliable than survey or questionnaire data in which people might give false answers tweets typically include a hashtag alongside a phrase or term which researchers follow spatially temporally and socially crampton et al for example followed lexingtonpolicescanner to find out how riots spread online in the us they suggest that researchers go beyond the geotag and focus on the space associated with the geolocation and not just the point on the map but it should be borne in mind that they were focusing on a localized event in one fixed location we argue against this practice as we have found that the geolocation which for us is the most important aspect is often omitted in secondary research analyses key words that link sports and twitter on web search engines at least in the english language typically identify research focusing more broadly on sports journalism and on finding sports events these results are linked to how the art of journalism has had to adapt to reporting news in different ways for example or how social media can be used alongside humans as realtime sensors to find out when sporting events are taking place smith et al point out that sports fans enhance their live sports viewing by using twitter this is a sentiment that has been noted in other studies not only among fans but also among coaches athletes and sports media associates originating in particular at the london olympics in 2012 which was known as the first social media olympics in summary the kind of volunteered geographic information mentioned above has long been used on other socialmedia platforms such as flickr photos and google maps placemarks which crampton et al call the geographies of the geoweb however what is missing from these examples is the vital aspect of our research namely where these tweets about sporting and news events are produced especially those in nonfixed locations a similar result would be found in data from mobile network infrastructures called transactional data which raun et al cite has the potential to reveal activity spaces for second home usage but still with a focus on the where and when of fixed locations although some sporting events are obvious this is not the case with less widely known or news events or informal leisure sports the where of an event should be attached to a specific and unique location and this spatial aspect is available as a geotag on twitter we are aware that users post about and interact with sporting events and we wonder if people in general also tweet about their own physical activities then when is not so important in our case given that many previous studies have focused on this such as zhao et al as well as lanagan and smeaton previous geotagged twitter tweet studies have begun to uncover land use functions including sportrelated urban land use such as iranmanesh et al but they do not mention which sporting activities and still omit the land cover type that the activity is occurring on there should hence be more emphasis on the more specific where which yields information for our study about which urban pa locations are popular in terms of user demand and could help municipalities to keep up their maintenance or improve the usability of locations in the hma we are aware that the city of helsinki already uses some people counters in specific outdoor pa spaces but although this example includes outdoor gym demand it omits all other types of pa that might go on in the hma members of the public have also noted that the maintenance of outdoor gyms could be improved and that this could correlate directly with user demand therefore twitter messages would be a more wellrounded data source of skiing tweets among a wider population as well as of other sportsrelated key words in the same locations methods study area we tested our approach in the casestudy area namely the helsinki metropolitan area with a total population of 12 million figure 1 shows each of the four areas as situated within the hma according to the lipas database the hma has a total of 5084 sports facilities helsinki espoo and vantaa are the top three municipalities in finland in terms of sports facilities the fourth being kuopio in the east and the fifth oulu in the north kauniainen ranks 240th out of 308 municipalities with 41 facilities in its 6 km 2 area we consider the hma to be one borderless research unit as residents typically live work and spend their leisure time freely across the four areas the respective municipalities therefore need to know the locations in the hma in which people engage in pa and spend their leisure time outdoors as well as the respective demands finlands climate is of the continental type being cold and with a long winter in the north and the interior and relatively milder along the western and southern coasts the hma lies on the southern coast but still averages temperatures below freezing and has snow most winters although the weather is becoming less predictable and these conditions cannot be guaranteed data we used two main types of data twitter tweets data and information from lipas sports facilities the twitter tweets comprise two combined secondary data sets one was collected by the digital geography lab at the university of helsinki and the other was part of an archive from the digital online life and you research project at the university of kentucky the total number of tweets amounted to 38487766 but it is worth pointing out that only a very small proportion of these contained geotags the temporal range of both the data is between september 2006 and april 2020 the lipas data on sports facilities are openly available for download and further analysis lipas is a nationwide database containing information about sports facilities in finland which currently number around 42000 and are all categorized we chose five skirelated types of facility ski tracks ski slopes and downhill ski slopes skijumping hill for training ski competition center and crosscountry ski parks we used these sports facilities locations in the results visualizations to find out if there were any matches between the sports and the tweet locations in the final visualization we display the individual tweets as points a tactic that has been successful in other studies for activity mapping in terms of space it is an effective way of disseminating results to designers for example who are familiar with using visual material to influence decisionmaking we additionally overlaid three landcover open polygon data sets from the web feature service of the city of helsinki lakes rivers sea and green space the hma boundary is as delineated in the helsinki region map methodology we followed the same methodology as koivisto did namely using both geotagged and geoparsed tweets although we only used the geotagged tweets in this analysis geotagged tweets inherently contain location information and are thus ready for further geographical analysis geoparsing is an additional method whereby a text location within the tweet is linked to geographical coordinates we used the programming language python to identify the geotagged sports tweets and the geographic information system software for manual data cleaning and analyzing the results visually twitter stopped allowing followers to use the precise geotag feature in june 2019 although still keeping a general geotag feature claiming that the majority of users did not use it the precise geotag feature allowed the exact longitude and latitude coordinates to be utilized whereas general geotags include a larger bounding box of a specific place such as a park or a city we therefore include data from september 2006 to april 2020 although some tweets came after this date twitter still allows users to post a precise location through a thirdparty app such as instagram or sports tracker hence our results include these in order to extract the sporting information from the tweets we filtered the tweet texts for the sporting key words to make the text in the tweets comparable we then normalized the words by means of lemmatization in other words returning to the dictionary form next we filtered the tweets by a list of sporting key words in both english and finnish tweets containing a word from this list were added to our data set an additional datacleaning task was to correct the filtered tweets manually to make sure that the action of skiing was being carried out we only kept the tweets whereby the tweeter was currently engaged in or had just completed the activity we removed the tweets if the tweeter was tweeting about another person or if it was in the future tense as we could not conclude with certainty that they had completed the action we were then left with firstperson action tweets we started with 278 skiing tweets but after the data cleaning we ended up with 150 we conducted a secondary analysis of tweets based on different key words that were located within a 100 m buffer zone as the remaining correct skiing tweets we used the same 19 key words as in koivistos analysis again restricting the languages to english and finnish we also removed the key words for iceskating and icehockey in both the english and the finnish tweets and kept only nonsnow sportsrelated activities table 3 shows the resulting filtered sports key word options we had 1076 other sportsrelated tweets but following the data cleaning we removed 296 incorrect tweets resulting in 745 correct ones tweets with more than one sportsrelated key word were counted again hence the sum counts of key words is higher than the number of tweets we counted the language of the key word and not the language of the tweet for the further analysis for which we therefore had 798 sportsrelated key words results and discussion our main research purpose was to find out how geotagged tweets detect informal pa spaces in the helsinki metropolitan area complemented with the subpurpose of identifying the type of urban public spaces in which people did their informal pa in section 22 we introduced green blue and street spaces which we explore below we categorize the results in terms of the need for municipalities to know where people are exercising and spending their leisure time outdoors and the respective demand first we give the results for the ski tweets and then we discuss the nonski tweets in relation to them we chose five locations with a tweet in both the ski and the nonski locations to give an example of a tweet with different features for analysis such as mentioning a location not mentioning a location or sharing a tweet via a thirdparty application there is an emphasis on what other types of informal activities are going on in these spaces that diverge from the spaces intended purpose we further discuss how our findings could help municipalities including sports planners and city planners to improve the conditions in locations in which user demand is calculated through tweet popularity figure 2 shows the skirelated tweets and figure 3 shows the tweets in the same locations but also includes other sportsrelated key words finally table 4 shows the counts of the overlapping tweets with the blue green and street spaces ski tweets ski locations figure 2 shows the results of the ski tweets spatial location is very important when analyzing tweets as the majority do not include a specific location within the text however it turns out that when they are added to a map output they are indeed in the correct location this is a key finding because it is not selfevident from the text results it is also a strong argument put forward by sloan and morgan who affirm that the geotag information is extremely valuable in that the tweeter decides to tweet at some point during an event or at a location in real time although in coakleys opinion informal sport participation is in decline our study has shown that people do engage in informal crosscountry skiing in the hma and they even tweet about it as figure 2 shows there are overlaps with the ski tracks and the skirelated types of sports facility there were tweets from close to six of the 10 skirelated facilities with a capture rate of 60 resulting in 50 tweets it is clear that these more formal facilities are also popular places for people to spend their free time these results would not have come to light if only a textual analysis had been conductedthe where is thus a very important aspect of this analytical method additionally two tweets mention the indoor ski tunnel at the kivikko ski center in helsinki however they are located in a street space even though the location of the ski center is within a green space this shows that our analysis could be limited by the scale of the background data the fact that we only used pregeotagged tweets raises a further discussion point in that we assume they are geotagged to a correct location that is mentioned within the tweet however some key definitions of informal sport in the current literature ignore the location as shown in table 1 even though there is not yet a main emphasis on the location where sport happens there were still two definitions that included it wheaton and oloughlin and deelen et al both use the term setting consequently if we divide the hma into green blue and street spaces the tweet results as shown in table 4 are 76 tweets in a green space 69 in a street space and five are in a blue space this could be broken down further into tweets along ski tracks ski tracks in total have a combined length of 5948 km and they are maintained by the municipalities most of the paths are within a green space accounting for 958 of all ski tracks hence skiing in the hma is also a form of green exercise in that the tracks go through parks and along forest paths additionally people follow selfmade tracks in the snow which are not counted in the total length of tracks they enable people to ski to the maintained tracks or just close to their home since people can go crosscountry skiing when there is enough snow on the ground shanahan et al make the overall claim that green spaces are important in terms of providing a location for physical activity and in particular with an emphasis on green exercise with its better health and wellbeing benefits in comparison to pa in builtup or indoor environments we do not focus on the specific health benefits in this article but it is obvious that the hma population has easy access to skiing tracks within green spaces next we consider which other sporting activities could be conducted in the same skiing locations when there is no snow ski demand finland offers opportunities to engage in outdoor exercise even in winter skiing being one major hobby to keep up with the recommended weekly target of 150 min of moderatetovigorousintensity pawhich according to bennie et al 70 of adult finns do not achieve the tweet counts match the population of the municipalities helsinki having the most and also the highest population count helsinki yielded 73 tweets espoo 58 vantaa 18 and kauniainen one there are other ways of tweeting than writing directly within the twitter site of the 150 ski tweets 60 came via instagram 39 via endomondo five from foursquare swarm which is a location diary shareable with friends and two from charity miles a sportstracking application for fundraising this leaves 44 that were directly written in twitter as figure 2 shows people living in the hma do not need to leave their local area to engage in winter sports or to do pa outdoors an example tweet is highlighted in solvalla swinghill ski center the user has tagged linked the ski centers the results sum to when accounting for recurring in the percentages twitter username the tweet so it could be said that the user was there at some point in time from the perspective of this paper then the additional information of location within the text is also beneficial an overall supply of crosscountry skiing locations is thus beneficial in promoting healthy cities if the municipalities know where the demand is in specific locations they could improve the maintenance of the tracks and facilities nearby such as providing more garbage bins benches to rest on and toilet facilities for example a negative aspect of improving facilities is that the routes could become overcrowded and this has a negative impact upon the environment korpilo et al found that this occurred during the use of nearby forests throughout the covid19 pandemic in the hma another negative aspect that is often cited is that urban spaces have decreasing amounts of green space however 574 of the hma is green space measured according to the green space layer and even then street spaces are still used for pa as these tweet results show it has also been found that engaging in pa improves overall health and wellbeing without having the extra stress of formal sports such as having to be present at a regular time each week and the extra costs involved bell et al also found that if the pa area is scenic and in natural surroundings people are motivated to work on their overall wellbeing in general then engaging in pa outdoors could be considered an inherently positive activity nonski tweets nonski locations next we focused on what ski locations are used for when there is no snow the green blue and street spaces are not just winter locations as they are open public spaces which is very common in finland figure 3 shows the results for the nonski tweets following the green blue and street analysis as shown in table 4 32 tweets were in a green space eight tweets were in a blue space and 705 in a street space this is a big contrast to the skitweet results the example tweet in the espoo figure is for the swinghill downhill ski center and the tweeter is tweeting about trail running multiuse outdoor pa spaces are not unique in finland but they are plentiful in comparison to other countries which was particularly evident during the peak of the covid19 pandemic some countries such as france even restricted the use of urban parks in england aside from the pandemic the countryside and rights of way act 2000 gives the legal right of public access only to about 8 of the countryside which severely limits opportunities for informal pa finnish forest areas such as central park in helsinki have specific paths to be used for skiing during snowy weather and during nonsnowy weather there are specific paths for cycling horse riding and walking however our results show only one tweet in this location of the 745 tweets 362 mention a location it is clear from this result that if the geotag were missing the location of the remaining 514 of the tweets would remain a mystery even with the additional step of geoparsing because there is no location to geoparse this also reflects hu and wangs concern about the removal of twitters precise geotagged tweets and its research consequences within the tweet location the results for nonski tweets reveal a cluster in helsinki city center which is the largest in the southern part of the map these tweets have the same coordinates which is the center of helsinki and therefore are located here when a tweeter tags helsinki as a more general location than where they are located this cluster comprises 220 tweets with another 123 surrounding it this type of tagging behavior is not so useful for further analysis because it means losing some of the data but it benefits the tweeter in not revealing the exact location mapping individual points has proven to be beneficial for the mapping of open spaces by researchers such as goličnik and ward thompson who mapped larger public parks and how their design limited user behaviors they concluded that larger open spaces were used for team sports such as football and that paths were mainly used for walking or cycling thus implying that urban design dictates how people should behave in a space an example of unusual behavior in a park is then to cycle across a grass field if there are paths around the edge this behavior setting extends to the inappropriate use of green spaces if many people similarly misbehave the result would be an area with muddy informal paths where the grass has been removed which in turn would lead to environmental degradation this scenario extends to urban forests korpilo et al reported the overuse of nearby forests during the covid19 period in helsinki nonski demand there were 745 nonski tweets 585 in helsinki 141 in espoo 19 in vantaa and none in kauniainen in comparison to the ski results there was a higher sum of tweets in helsinki compared to the other three municipalities accounting for 785 of all the nonski tweets in terms of where the tweets are posted from 440 were via instagram 103 via endomondo 27 via foursquare swarm and 77 via charity miles the remaining 98 were posted directly from twitter figure 3 shows five examples of tweets representing four different types of sport but in the same location as the examples of ski tweets given in figure 2 environmental decisions could promote healthy living in specific urbandesign and social settings if it is known where people engage in pa municipalities could plan more effectively where to put more facilities such as bike racks and starting routes from publictransport stops another example is where people follow specific routes created by the municipalities to both control and increase outdoor pa decisions have to be made such as where to place garbage bins toilets and signposts to specific routes there has recently been increasing interest in designing walkable cities as a consequence of the covid19 pandemic knowing the tweet demand may help municipalities to improve locations to make people feel more comfortable and willing to spend longer outside the results in combination create a new and more comprehensive data set concerning the demand for informal sporting locations that the municipalities in the hma could utilize to better allocate funding for improvements such as those facilities mentioned above in relation to jeanes et al who focus on sports policies the data and information that have been produced from the tweet locations can serve as a tool that helps municipalities to include the practices of knowledgebased management into their daily work the information can be used by city or sports planners when they know where informal sports and pa spaces are being utilized in order to help plan facilities and cities in such a way that access is equal for the population this is a key idea and result as we have shown that a wide variety of sports are conducted in the same outdoor locations even when restricting our study to 16 sports keywords this further means that the population already feel welcome to use these locations at any time or location which formal sports might restrict but improvements can still be made so that a wider population has access to outdoor pa spaces conclusion gilchrist and wheaton note the difficulty in finding out participation rates for informal sports and we took this as an opportunity to gather a usergenerated data set of twitter tweets we have shown that even with a very small subset of an already limited portion of data that is geotagged it is possible to obtain sound results for further analysis we detected informal spaces for skiing activity that might otherwise be ignored in efforts to understand where people engage in physical activities in the hma improving the health of the population through facilitating engagement in informal sports is a simple and costeffective form of intervention to reverse the increase in illnesses related to physical inactivity which costs the country billions annually we further focused on other types of informal activities going on in these spaces that differ from the intended purpose to shed light on the pa that goes on in the same locations when there is no snow the hma is a very inclusive area from a sports facility perspective and therefore allows the population to have many different opportunities for maintaining active and healthy lifestyles our results support the suggestion put forward by neuvonen et al that the hma has been designed and maintained so that everyone has equal access to outdoor spaces regardless of whether or not they realize they like to be outdoors doing pa informal sports do not require regular monetary or time commitments and are therefore suitable for a larger proportion of the countrys population informal sports often require less regular monetary or time commitment than organized sports and therefore may be suitable for a larger proportion of the countrys population our research can therefore be expanded to a national level and a wider variety of sports to capture any variations between municipalities to locate which populations are less active in using social media to post about their pa a further research aspect could be the impact of climate change upon the skiing possibilities in the hma our results have already shown that the population do conduct other types of pa in the same locations but it would be interesting to find the types of pa during a less snowy winter finally future research should focus on detecting pa spaces using the 90plus percent of tweets that do not have a geotag this involves complex geoparsing to add the missing locational information and in potentially revealing different demands of informal spaces that are not currently known could be a valuable method to test it is difficult to create national policies focusing on informal sports because it means taking a step back and letting the population do their own thing away from formal sports facilities the more traditional datacollection methods involve surveys which are open to exaggeration on the part of the participants or the giving of false information as mclaren and shanbhogue found it is therefore more difficult to know how many people and more specifically who use the informal outdoor facilities and if they even bring about change in sedentary lifestyles overall we conclude that twitter may be a beneficial tool in detecting yearround spaces for informal physical activity the benefits could extend to city planners and sports planners aiming to improve informal sports facilities based on user demand and thereby promote the development of healthy cities data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction finlands natural physical environment and climate support a wide variety of informal outdoor sports thereby motivating the population to do physical exercise in scenic environments the vast majority of finns enjoys outdoor recreational activities and could thus be encouraged to post accounts of their yearround activities on social media our aim was to find out in what kind of areas and spaces spatially users are tweeting about sporting activities methods we use geotagged twitter tweets filtering for sporting activity keywords in both english and finnish the case study was conducted in the helsinki metropolitan area finland with an emphasis on crosscountry skiing as a sports activity when there is snow in a secondary analysis we concentrated on the sports people were practicing in these locations when there was no snow the location spaces are split in to three land cover types green blue and street spaces results we found that approximately half of the skiingrelated tweets were geotagged in green spaces and half in street spaces this finding related to street space was attributable to a spatial scale error when we checked the results manually we noticed that they referenced the sporting location in the green space hence then over of the nonskirelated tweets were geotagged in a street space discussion we conclude that twitter is a beneficial tool for detecting spaces used for informal physical activity a shortcoming in current finnish national sporting policies is that spaces for informal physical activity are not explicitly mentionedwe use the term informal with reference both to the space and to the sporting activity whereby public spaces are used for physical activity this new knowledge of sporting locations will help city planners and sports planners to improve informal sports facilities which in turn will promote healthy exercise in cities

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background the proportion of oneperson households has doubled during the past three decades with every third person in the us and the uk living alone 12 it has been estimated that by 2020 nearly 40 of all households will have only one inhabitant 3 at the same time there has been a dramatic increase in the consumption of antidepressant medications 45 the potentially catastrophic consequences of single living were evident during the 1995 heat wave in chicago when most of the deaths occurred among elderly people living alone 6 however the longterm consequences of single living are poorly understood because never before in history has there been such a great proportion of people living alone living alone has been associated with psychological disadvantages and an increased risk of mental health problems higher rates of consumption of psychotropic drugs 7 8 9 10 11 12 and a higher risk of suicide 13 compared to living with other persons in the same household a prospective study demonstrated that household structure that is the social composition of people who reside in the same household was a more important determinant of wellbeing than marital status in middleaged people 14 however most studies in this field of research have been crosssectional and have concentrated on selected populations such as elderly people living alone 1516 or single parents 17 little is known about the mental health outcomes associated with single living in economically active people who represent the majority of the workingage population 1318 several possible reasons may explain why people living alone suffer from poorer mental health and why people living with others generally have better mental health living with other persons may offer emotional support feelings of social integration as well as tangible factors that protect against mental health problems 161920 living alone in turn may be associated with psychosocial deficits such as feelings of isolation 13 19 20 21 22 and a lack of social integration and trust which in turn are risk factors for mental health 23 24 25 single people may also face distress due to socioeconomic disadvantages such as financial difficulties and they may be prone to adverse health behaviors 19212226 in workingage people single living may be associated with poorer wellbeing in working life which in turn is known to be a predictor of mental health problems 2427 we are aware of no previous study that has examined aspects of working life as potential contributors to the association between living arrangements and mental health outcomes in the present study we used antidepressant medication as a proxy measure for the most common mental disorders 28 as antidepressants are indicated for both depression and anxietyrelated conditions our aim was twofold to examine 1 whether living alone was associated with antidepressant use during a 7year period and 2 the extent to which psychosocial socioeconomic and behavioral factors explained any observed association between living alone and the use of antidepressant medication this study was based on data from finnish workingage men and women who formed a representative sample of the finnish working population methods measures living arrangements were examined at the baseline examination between august 15 2000 andfebruary 28 2001 the participants were asked how many persons live in your household including you the participants were classified as living alone if they reported a household size of one person and not living alone if they reported a household size of two or more persons the validity of this question was examined by crosstabulating living arrangements with selfreported marital status of the 504 persons living alone 184 were divorced 25 widows and 295 lived alone without a specific reason there were 13 married persons living alone we decided to retain them among the 504 persons who were classified as living alone as they might have been separated but not yet divorced information on antidepressant medications purchased at pharmacies between january 1 2000 and december 31 2008 was obtained from the national prescription register managed by the social insurance institution of finland this register covers the entire outpatient population and all reimbursed doctorprescribed medications in finland participants who had purchased at least one prescription coded as n06a were considered as antidepressant users three variables were formed baseline users users at followup and incident users psychosocial factors included selfreports of a poor job climate 31 a lack of support at the workplace 32 a lack of social support in private life 33 and cynical hostility 34 participants not currently working were asked to report the working conditions during the previous 12 months for all psychosocial factors the highest tertile represented those rated high in the characteristic there were two main reasons for using categorical variables instead of continuous ones it enabled a better comparison with previous studies using similar measures 2735 and the assumption underlying the use of continuous variables is that each increment in the distribution equally adds risk but this is not necessarily the case as threshold effects are possible in a study where the outcome is a dichotomous mental health variable sociodemographic factors were a low occupational grade a lack of educational qualifications a low household income currently being outside work life urban residency rental living and poor housing conditions health risk behaviors included daily smoking heavy alcohol use low physical activity and obesity data analysis the data were analyzed using sas 91 survey procedures and sudaan 9 software this software applies weighting adjustments and sampling parameters to account for the clustering of a stratified sample we used logistic regression analysis to examine the association of the living arrangement with the odds for having purchased reimbursed prescriptions of antidepressant medication these analyses examined a the crosssectional use of antidepressants b the longitudinal use of antidepressants and c incident use of antidepressants we entered socioeconomic factors psychosocial factors and health behaviors as separate blocks in the ageand genderadjusted models and we calculated the percentage change in the odds ratio to evaluate their influence on the association between living arrangements and antidepressant use these analyses were conducted in all participants and additionally stratified by gender results characteristics of the study variables according to gender are presented in table 1 of the 3471 participants 145 reported living alone with an equal proportion of men and women living alone the prevalence of antidepressant use in all participants was 62 at baseline and altogether 172 used antidepressants at some point during the 7year followup period each year 1 to 2 of participants started to use antidepressants and the prevalence of incident use during the entire followup period was 129 women had a greater prevalence and incidence of antidepressant use than men compared to women men had less social support at work and a lower occupational grade than women more often lived in rural areas smoked more often and used alcohol more heavily than women table 2 presents psychosocial demographic and behavioral factors according to living arrangements participants living alone experienced a worse job climate less support in private life had a higher level of cynical hostility were more often nonemployed lived in urban areas were more likely to live in rental accommodation had worse housing conditions were more often smokers and used alcohol more heavily than those who did not live alone when comparing purchases of antidepressants those living alone had purchased antidepressants more often than those who did not live alone at the baseline examination likewise during the followup period 254 of persons living alone versus 158 of others had purchased antidepressants in any year between 2002 and 2008 as shown in table 3 living alone was associated with a 161fold higher purchase rate of antidepressants at baseline and 181fold higher rate during the 7 following years compared with people who did not live alone when the analyses were restricted to participants who started antidepressant use after the baseline examination the association remained similar sociodemographic factors attenuated these associations by 18 21 and 20 as shown in table 3 the ors adjusted for sociodemographic factors were 148 for baseline antidepressant use 164 for 7year use and 157 for incident antidepressant use psychosocial factors attenuated the associations by 30 12 and 6 with the adjusted ors being 143 for baseline use 171 for 7year use and 167 for incident antidepressant use finally health behaviors had only a marginal effect on the associations between living arrangements and antidepressant use with adjusted ors of 158 174 and 164 corresponding to a contribution of 5 to 9 owing mainly to heavy alcohol use there was no statistical evidence to suggest that gender modifies the association between living arrangements and antidepressant use however the underlying mechanisms could be genderspecific thus we ran the analyses shown for the total cohort in table 3 stratified by gender to examine whether the contributing factors differed between men and women table 4 shows that in men psychosocial factors had the greatest contributing effect on the association between living arrangements and antidepressant use in women sociodemographic factors stood out as the major contributors showing attenuations of 24 27 and 31 finally we conducted a sensitivity analysis to examine whether the associations were dependent of the length of the followup period we repeated the analysis of living arrangements and antidepressant use for a 2year instead of a 7year followup period the association was directionally similar but slightly weaker than in the main analysis the contributing factors were similar in magnitude to those in the main analysis with sociodemographic factors having the greatest contribution and health behaviors the lowest contribution to the greater antidepressant use of participants living alone discussion this study suggested that living alone is associated with the prospective use of antidepressant medication in a nationally representative finnish workingage sample those who lived alone had an 80 higher risk of initiating antidepressant use during the 7year followup compared with participants who did not live alone socioeconomic adversity explained part of this relationship especially in women psychosocial factors including a lack of social support were important explanatory factors in men health behaviors had only a marginal contribution to the association between living alone and antidepressant use among men and women with the exception of heavy alcohol use in men this is in agreement with a previous registerbased study showing a strong link between living alone and alcoholrelated mortality 36 all the factors included in this study explained 46 of the associations thus leaving the majority of the association between living alone and antidepressant use unexplained our findings are in line with previous reports suggesting that single people suffer from ill health due to material and socioeconomic disadvantages 1921 in our study urban living poor housing conditions and rental living contributed to the association between living alone and antidepressant use their effect was more pronounced in women than men a systematic review demonstrated that the very same environmental factors housing quality housing tenure and urban living had the strongest mental health effects 37 the direction of causality in our study may go either way poor living conditions may cause depression but they may also be a consequence of earlier mental health problems a lack of social support a poor job climate and a hostile personality were among the psychosocial factors that were associated with living alone and antidepressant use a lack of supportive social contacts at work and in private life explained part of the association between living alone and antidepressant use in men previously social problems at work and in private life have been associated with antidepressant consumption 2427 the concept of social capital may offer a theoretical framework for interpreting these findings living alone may be associated with less social capital 13 19 20 21 22 which in turn is a risk for mental health 23 24 25 as hostility is a rather enduring personality characteristic associated with irritability lack of trust and negative social interactions 38 reverse causation may also play a role hostile personalities may be more likely to end up being without a partner due to unwillingness or a lack of skills to form warm and close social relations our data were limited firstly due to the systematic dropout causing healthier and economically betteroff individuals to be slightly overrepresented this may have restricted the variance in both the predictor variable and in the outcome variable thus underestimating their effects second we were unable to examine whether changes in living arrangements had an effect on antidepressant use as we had no data on living status on followup some misclassification was possible due to changes in living status after baseline that is someone who was originally living alone may have been cohabiting at the time of purchase of antidepressants although the main findings were replicated in sensitivity analyses over a shorter timespan when a change in living status was less likely this question remains to be examined in further studies moreover we had no data on antidepressant use before the baseline measurement and thus were unable to examine reverse causation that is whether people with prior depression are likely to drift into living alone although we showed that living arrangements were associated with starting to use antidepressants inferences on whether living alone causes mental health problems are not possible based on this observational data set third different reasons for living alone may be differently related to mental health but we were unable to compare individuals who unwillingly lived alone with those living alone through choice neither were we able to measure the effect of different household compositions on mental health such as the presence of children a spouse or elderly relatives a large prospective study has shown that under certain circumstances living with other people may be more stressful than living alone 14 future studies should examine the possible benefits of living alone and the advantages and disadvantages of having other persons with different statuses in the household furthermore antidepressant use as the outcome variable may reflect helpseeking behavior or differences in access to health care people using antidepressants have depression that has been diagnosed by a health care professional and people with undiagnosed depression were not therefore identified moreover people typically seek help if the disease is severe enough to cause functional disability 39 suggesting that participants with mild depressive symptoms may have been undetected this may have resulted in underestimation of the number of depressed people and underestimation of the effects finally some antidepressants particularly tricyclic medication are commonly used for nonpsychiatric indications such as pain or sleeping problems 1240 however it is unlikely that the indication of antidepressant use varies according to living arrangements 12 the strengths of this study were that common rater variance was excluded because the sources of information on the outcome and contributing factors were independent of each other because all purchases of antidepressants are recorded in the national registers in finland we were able to track 100 of participants who had purchased antidepressant medication at least once during the study years we included a rather extensive set of wellestablished risk factors for mental health problems to our knowledge this is the first study to examine both private life and work life factors as contributors to the association between living arrangements and mental health outcomes within the same sample conclusion this study focused on a workingage population and its antidepressant use over almost a decade persons living alone faced several types of psychosocial and material disadvantage we found evidence to suggest that the explanatory factors may be gender specific with a lack of social support playing a greater role in men and socioeconomic disadvantages in women these finding suggest that improving the quality of social relations and material circumstances should be important targets in mental health promotion further research is needed as over half of the association between living alone and antidepressant use remained unexplained by the variables included in this study further insights may arise for example from assessments that cover social capital critical life events and their accumulation over time and childhood circumstances giving rise to psychological vulnerabilities in adulthood additional material additional file 1 prevalence and incidence of antidepressant use according to followup year the health 2000 study n 3471 additional file 2 odds ratios for use of antidepressants during a 2year followup period in participants living alone compared to participants not living alone data the health 2000 study n 3471 authors contributions l pr was the principal investigator conducted the data analyses wrote the first draft and will act as guarantor for the paper mk ka kj me hr sp sk jl and mv substantially contributed to conception and design of the study interpretation of data drafting the article critically for important intellectual content and approved of the final version all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background an increasing proportion of the population lives in oneperson households the authors examined whether living alone predicts the use of antidepressant medication and whether socioeconomic psychosocial or behavioral factors explain this association methods the participants were a nationally representative sample of workingage finns from the health 2000 study totaling 1695 men and 1776 women with a mean age of 446 years in the baseline survey in 2000 living arrangements living alone vs not and potential explanatory factors including psychosocial factors social support work climate hostility sociodemographic factors occupational grade education income unemployment urbanicity rental living housing conditions and health behaviors smoking alcohol use physical activity obesity were measured antidepressant medication use was followed up from 2000 to 2008 through linkage to national prescription registers results participants living alone had a 181fold ci 146223 higher purchase rate of antidepressants during the followup period than those who did not live alone adjustment for sociodemographic factors attenuated this association by 21 adjusted or 164 ci 132205 the corresponding attenuation was 12 after adjustment for psychosocial factors adjusted or 171 ci 138211 and 9 after adjustment for health behaviors adjusted or 174 ci 141214 genderstratified analyses showed that in women the greatest attenuation was related to sociodemographic factors and in men to psychosocial factors conclusions these data suggest that people living alone may be at increased risk of developing mental health problems the public health value is in recognizing that people who live alone are more likely to have material and psychosocial problems that may contribute to excess mental health problems in this population group

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introduction the topic of social security systems in early islamic history is an important and understudied area of scholarship one of the most significant examples of such a system can be found in the reign of umar ibn alkhattab the second caliph of the islamic empire under his leadership a comprehensive social security system was implemented that provided for the welfare of the empires citizens particularly the poor and vulnerable this system which was grounded in islamic principles and values was considered to be a model for the provision of welfare in islamic societies for centuries to come this paper aims to examine the social security system under the reign of umar ibn alkhattab with a focus on its key features institutions and impact on society humans require social security in order to survive this is necessary due to sudden illness death disability disease unemployment fire flood storm drowning and transportationrelated accidents as well as the resulting financial loss a victim and his dependents frequently slide into poverty as a result of these traumas their financial situation deteriorates to the point where they require assistance due to this reality social security must be viewed as a fundamental requirement that applies to a very broad variety of human endeavors and circumstances it would be appropriate to quickly consider both the modern and islamic concepts of social security before getting into the real subject of this article contemporary understanding of social security and welfare in the event of certain occurrences such as unemployment an accident a handicap or death at work the state must at least provide its citizens with social security when it comes to ensuring a wider level of welfare for the states citizens the provision of this kind of social security is becoming increasingly wellknown 1 the phrase social security refers to legal initiatives that offer an individual and his family financial security and social welfare 2 certain authors in europe attempt to link some practices from the late medieval era to the development of these laws truth be told it was not until the close of the last century that europe first became familiar with social security regulations 3 at the moment these programs are made to give people benefits and services in the event of their retirement illness disability passing away or unemployment it specifically refers to the section of the act dealing with social insurance which makes use of company and employee contributions to pay out income to persons and their families in retirement or in the event of unemployment disability or death the islamic approach to social security and welfare islamic social security is based on the idea that everyone who is unable to meet their own requirements should have their basic needs met it refers to ensuring that all people of an islamic state regardless of their class or belief have access to the needs of life 5 understanding the islamic social security systems philosophical underpinnings is crucial for comprehending this idea it is not found in capitalism communism or even european socialism rather it is found in the harmonious fusion of material and spiritual requirements in contrast to other social security system conceptions which are the product of human thought islams social security system is divine in nature and is wholly founded on the quran and sunnah it is a method to achieve the high standard of morality expressed under the term righteousness to believe in allah the last day the angels the book and the messengers to spend of your wealth out of love for him for your kin for orphans for the needy for the wayfarer for those who ask and for the ransom of slaves to be steadfast in prayer and give zakah to fulfill the contracts which ye have made and to be firm and tolerant are all acts of righteousness according to the holy quran 6 the quran places a great deal of weight on providing material aid to the needy and the destitute in light of the tasks that are commanded in the aforementioned verse and which man is required to fulfill in life the quran is so considerate of the lower socioeconomic strata that it exhorts every earning member of society to show compassion for gods creation by doing acts of charity the quranic verse after that attests to this by no means shall ye attain righteousness unless ye give of that which ye love and whatever ye give allah knoweth it well 7 islamic state prioritizes social security as a means of ensuring its residents sustenance and comfort in addition each individual is held accountable for the wellbeing of the others this viewpoint has been incredibly wisely stated by prophet muhammad as everyone is a keeper unto every other and responsible for the welfare of all 8 in an islamic community wealthy people are obligated to care for their less fortunate brethren alquran 597 states that wealth should not be restricted to the wealthy according to verse 429 of the quran it must be grown for a useful purpose and must be traded for it is crucial to stress at this point that the zakah system which mandates the payment of alms is the most significant institution that carries out the concept of social security in islam 9 it is actually supported by infaq fi sabillillah and nafaqat alwajibah and the prohibition of riba 10 islam bases its idea of social security on the highest moral standards islamic teachings on tawhid rislah and khirah are imbued in such a way as to reach a persons heart and inspire feelings of comradeship and devotion for others causing a person to enjoy doing good deeds this individuals conduct toward society ensures the welfare of everybody and treats the societal issues brought on by selfishness on the other hand divine law offers social justice which places a strong emphasis on giving people their proper compensation as a result no member of society is uncared for public welfare and social security are the top economic duties of the state in an islamic economic system people who are in need due to an unexpected disaster a hereditary condition a temporary job loss old age or the natural death of the family guardian should have their needs met by the state 5 noor muhammad ghifari social security in islam lahore atiq publishing house p 23 6 abdullah yusuf ali english translation and commentary the holy quran madinah king fahd holy quran printing complex 7 ali english translation and commentary the holy quran 8 sahih bukhari kitab aljuma fi alqura wa almudun no 893 and sahih muslim kitab alimara no 1829 9 alquran obligation of zakah 24043 283 2177 2280 477 4159162 512 555 6141 9711 918 971193031 195455 21 72732256227824372456273303933335813732031303039 naturally the level of social security will be influenced by both the socioeconomic environment and societal standards in general the state should fulfil these commitments using its own resources but in some circumstances it might also be necessary to use some unique sources for instance the government manufacturers and other employers may be obliged to shoulder the responsibility on behalf of its employees and workers just as the wages and salaries the employees can also be requested to make some contribution to the scheme during their employment 11 most likely firms and businesses should have their own zakah funds to augment existing social security programs the social security policies of caliph umar ibn alkhattab from tripoli to balkh from armenia to sindh and gujrat and over the nations en route including syria iraq and iran the muslims governed during the reign of caliph umar ibn alkhattab 12 the best time in the history of the islamic social security system was under the rule of umar ibn alkhattab social and economic fairness won and each state resident received their fair part 13 sense of accountability umar ibn alkhattab was highly concerned about the citizens social security in his capacity as ruler of state here are some of his quotes that demonstrate his sense of accountability the caliph is the supporter of him who has no supporter 14 and each and every individual muslim has a right in the property of the state treasury whether he exercises it or not 15 he has also been attributed to be repeating that i am very much anxious that whenever i come to know of some ones need i should fulfil it immediately as far as we can individually meet the needs of one another we should do so but when we cannot do so individually then we shall do collectively until the standard of living of all of us is equalised alas you do not know my sincere feelings about you but i want to explain them only through practice by allah i am not a ruler that i enslave you caliphate is the trust of allah it is my duty to follow you till you sleep in your home with your bellies full of meal thus i shall be successful in but if i compel you to follow me till you knock at my door for your needs then i shall be condemned i may make pleasant here for a few days but thereafter i shall have to worry for a long period then none will listen to me and none will respond if i beg his pardon 16 given the information above it is simple to imagine how accountable a head of state should be for the social security of their people bureau of social welfare the social security system was first implemented by umar ibn alkhattb the first king in recorded history social security formed a department to guarantee the provision of the needs of life to the states indigent residents a detailed census and registration of the citizens was conducted there were various categories for social security registration 17 the muslim communitys stipends and allowances were graded in accordance with their merit in light of islam 18 bureau of public treasury the most crucial resource for a countrys social security system is state money the income of the treasury department significantly grew under the caliphate of umar ibn alkhattb thanks to his shrewd and severe administrative methods zakah ushr adaqt jizyah and khums were all credited to the treasury for the benefit of all muslims for instance the muslim gained significant booty during the victories of yarmuk and qdisiyyah the madinah almunawwarah coffers were overflowing with money 19 the islamic social security system seeks to meet every demand a person could possibly have these requirements can be broadly divided into two categories primary needs such as food clothing housing and necessary medical care secondary needs such as education marriage old age benefits and social services among others we will now examine the social security system under the reign of umar ibn alkhattab in light of the aforementioned categories nourishing security ensuring access to adequate food supply in times of severe hunger or drought in arabia umar ibn alkhattb requested the provincial governors of syria iraq and egypt provide food grains and other needs for the populace which were distributed based on family size all those from the interior of the desert who sought refuge in madinah almunawwarah were fed every day at state expense and meals were prepared at the state level one account claims that up to 40000 people were fed each day 20 another version states that each muslim and the slaves received two weights of wheat two weights of olive oil and two weights of vinegar each month21 providing financial security to those in need assisting disabled individuals and lowincome families on one occasion umar ibn alkhattab observed a person eating with his left hand he questioned him about why he was using his left hand to eat o slave of allah was the reply my right hand is occupied how come umar ibn alkhattab questioned it was cut off in the battle of mutah he retorted as he was sobbing he knelt down next to him and inquired who helps you in ablution after hearing this who gives you a head wash who does the laundry for you then he assigned a servant to assist him gave him a residence and supplied for his basic needs22 empowering neighborhoods through access to opportunities and financial stability education is one of the top concerns in the islamic social system for achieving social security umar ibn alkhattab appointed and paid teachers for the education of boys for this purpose from the treasury department three people used to instruct the kids in madinah almunawwarah according to wudayf ibn ata they received 15 dirhams from the treasury division thanks to umar ibn alkhattab the best qurra were to be listed by the governors so that they may be appointed to greater stipends for public education across the nation23 empowering marriage with financial security the benefits of matrimonial allowance islam pays particular attention to human carnal impulses in order to uphold societal standards unmarried poor people of both sexes received financial assistance from the treasury department to lead a married life under the reign of umar ibn alkhattab he requested in a letter to the kufah governor that the needy unmarried individuals receive a marriage allowance24 social security benefits for the elderly the government of umar ibn alkhattab provided yearly stipends to the elderly men and women 25 when the caliph umar saw an elderly jew panhandling he took him to his home he gave him some money and instructed the treasury officer to award stipends from the public treasury to those who were unable to support themselves 26 social welfare through investment opportunities due to the chance that future administrations might not be able to provide them with stipends umar ibn alkhattab used to advise stipend recipients to invest their money in the acquisition of herd and cattle for their future economic survival 27 boosting social welfare loans the treasury department provided loans to the merchants for a predetermined amount of time on a mudarabah basis 28 for people who had shortterm requirements caliph umar ibn alkhattab offered an interestfree loan service with a guarantee of payback it was available to the caliph for personal use this demonstrates unequivocally how islam forbids taking an interest in its socioeconomic system 29 assistance with the payment of debt the treasury department assisted those who were in debt to pay off their bills which is a salient aspect of the rule of umar ibn alkhattb 30 social insurance the application of state expenditure for a form of social insurance is another distinction made during the reign of umar ibn alkhattab under this head of budget the government would assist a person convicted of involuntary homicide who was unable to pay the blood money required by law on his own 31 stipends widows married and unmarried women young men and immigrants received yearly stipends from the government of umar ibn alkhattab 32 fighters and volunteers received set amounts from the fay while the poor and needy received payments from the zakah ushr and sadaqat 33 the social security system developed to such a powerful level during the magnificent reign of umar ibn alkhattab that people wanted to pay zakah but no one was available to receive it the newnursing borns and breeding costs were covered by treasury funds and the parents received a newborn allowance a youngster initially received 100 dirham annually this amount was later increased 100 dirham was set aside as a compensation for the unclaimed children 34 overall mechanism for social security and welfare the islamic social security has a considerably broader scope of operation than the others during the rule of umar ibn alkhattb guesthouses were built in significant cities to serve as resting places public use roads and bridges have been built shelters wells and supper houses were built at various points along the madinah almunawwarah to makkah almukarramah road in order to accommodate travelers who become weary before arriving at their destination or run out of provisions canals were built to supply the populace with drinking water as well as to irrigate crops the ninemilelong abu musa canal carried water from the tigris to basra maqal canal another canal was also excavated from the the tigris a canal known as the amir almuminῑn canal was dug to join the nile to the red sea35 financial aid for the nonmuslims nonmuslim minorities in an islamic state are referred to as dhimmis which is arabic for the protected of god and the prophet the nonmuslim subjects of an islamic state are likewise guaranteed their basic material requirements by islamic shariah i commend my wish and testament to him who will be the caliph after me the caliph umar ibn alkhattb once said god and the prophet provide protection for the dhimmis respect the agreements youve made with them stand up for them when required and dont give them any obligations they cant handle 36 jizyah a submission price is imposed by the islamic state on people who practice another religion yet need protection jizyah thereby ensures the safety of their lives and their possessions it is based on the clear command of alquran 929 the poor ill elderly and nonmuslims who served in the military were free from jizyah under the reign of umar ibn alkhattb 37 umar was concerned for the happiness and wellbeing of the islamic states nonmuslim subjects when hudayfah and uthman ibn hunayf once returned from the tigris river area carrying money for the kharaj umar ibn alkhattb questioned them have you gotten from the dhimmis more than you can pay whatever is left with them is considerably larger than what has been received hudayfah retorted i have left with them double to this uthman retorted when he heard this umar ibn alkhattab said these words to convey the significance of the issue by allah if i were still living i would make provisions for the widows of iraq such that they would no longer want the financial assistance of any caliph after me 38 under the leadership of umar ibn alkhattab the department of social security opened its doors to both muslims and nonmuslims in actuality it was an entire social insurance system when returning from a trip umar ibn alkhattb saw some nonmuslim lepers and ordered that all of these individuals receive support from public finances without regard to their religion the needy received stipends from the treasury the treasury officer was given instructions to interpret the quranic mandates that sadaqat be given to the needy and the destitute as meaning the poor muslims and the needy jews and christians respectively39 conclusion the social security system under umar ibn alkhattab was characterized by a number of key features first it was based on the principle of zakat or charity additionally the system was also based on the principle of taxation with the revenues collected used to support the welfare of the empires citizens this system of taxation helped to ensure that the empires resources were distributed fairly and that the needs of the poor and vulnerable were met under umars leadership a number of institutions were established to manage and distribute the funds collected through zakat and taxation these institutions included the bait almal or public treasury which was responsible for collecting and distributing funds to the poor as well as the diwan alkharaj or bureau of taxation which was responsible for collecting taxes from the empires nonmuslim subjects these institutions were established to ensure that the needs of these specific groups were met and they played an important role in the social security system the waqfs for example helped to provide for the education and care of orphaned children while the asylums helped to provide for the elderly and infirm the social security system under umar ibn alkhattab represented a significant development in the provision of welfare in islamic societies it was based on islamic principles and values and it provided for the welfare of the empires citizens particularly the poor and vulnerable the system remains a model for the provision of welfare in islamic societies and continues to be studied by scholars of islamic history and social welfare

islams social security system differs in nature and operation from the social security systems that are widely used around the world the muslim world has had access to a commendable social security system from the beginning of islam therefore modern social security systems are nothing new to them in this article the islamic social security system under the rule of umar ibn alkhattāb the second khalifah of islam is studied historically

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digital footprints an emerging dimension of digital inequality the digital inequality literature has focused on the antecedents and effects of differentiated internet use more specifically this line of research has called attention to certain online dimensions in which offline inequalities are reproduced dimaggio and colleagues distinguished between internet access skill availability of social support and variation in use while van dijk distinguished between motivational access material access skills access and usage access both conceptualizations show the multidimensionality of digital inequalities and the importance of differentiating dimensions when analyzing the phenomenon across all dimensions the scientific and public policy relevance of the digital divide is based on the assumption that those who are able to effectively use the internet might increase their social economic cultural and human capital consequently if users in privileged social positions have better conditions for internet access skills and use social inequalities may be exacerbated in this article we propose that predominant digital inequality frameworks should be extended to include a new dimension digital footprints we define digital footprints as the aggregate of data derived from the digitally traceable behavior and online presence associated with an individual not only internet use but also individuals digital footprints can lead to beneficial and adverse outcomes shortterm or longterm individual or societal what users do online matters but what is online about them also has consequences as with actual footprints digital footprints are not a complete picture of a person but they do allow diverse inferences of varying accuracy we therefore argue that digital inequality scholarship should consider how digital footprints vary according to sociodemographic variables and traditional markers of inequalities moreover this line of scholarship should outline potential consequences of varying digital footprints and how they might then contribute to the reproduction of social inequalities digital inequality research needs to explicitly account for the power imbalance between digital platforms and users in the current digital environment as well as the role of big data in reproducing inequalities the increasing use of algorithms and artificial intelligence across various life domains necessitates a thorough investigation of digital footprints specifically many algorithms rely heavily on personal datanot necessarily just online datato automate complex tasks in the background for instance automated decisionmaking through personal databased algorithms occurs in the context of social media content curation social credit scoring recommender systems in online shopping and entertainment environments hrm and hiring practices and justice systems where algorithms attempt to predict recidivism various examples such as microsofts tay chatbot have demonstrated how algorithms can become problematic raising ethical questions about transparency accountability bias and discrimination in particular the issues of bias and discrimination are strongly connected to social inclusion and the representation of individuals as data subjects recent work has shown how systemic biases such as racial and gender stereotypes can be embedded into ai systems across search engines chatbots and face and voice recognition technologies widely used on social media in that sense algorithms and ai have become important topics within research on social inequalities and ethics in the digital society in general the notion of a digital footprint gap was first elaborated by robinson et al in the context of digital inequalities over the life course referring to data posted by adults about children within this approach the term digital footprint gap describes the differences in the amount of online traces between individuals or population groups we propose to extend this concept considering not only the quantity but also the quality and most importantly the implications of online traces for reproducing inequalities therefore we ask how do different social groups vary in their digital footprints and subsequently how do these quantitatively and qualitatively varying digital footprints produce outcomes that affect social inequalities to a certain extent the ability to manage ones own digital footprints successfully can be understood as a component of digital literacy in fact being digital media literate does not solely stand for the ability to find and critically analyze online information but also for being able to effectively securely and successfully use digital media in order to communicate collaborate share knowledge and express oneself all these activities involve leaving online traces therefore the ability to maximize the benefits deriving from digital footprints while reducing the disadvantages stemming from limited suboptimal or negative digital footprints is certainly included into the broad notion of digital literacy while digital footprints are not an entirely new dimension in digital inequality scholarship we contend that research in this area has not systematically investigated this notion yet the topic has only been partially addressed especially by research on online privacy management and skills and online content creation research on privacy has shown that internet skills themselves dependent on education strongly explain privacy protective behavior and thus the shaping of digital footprints social network sites make the task of managing privacy increasingly challenging to the point that some users have developed a form of apathy and cynicism feeling that privacy violations are inevitable yet understanding which personal information should not necessarily be available to others and knowing what to do about protecting such content is a type of skill that varies considerably across the population lowincome internet users are still less likely to engage in privacyprotective strategies on social media and are more likely to report having experienced problems related with their online data such as having their reputation damaged because of something that happened online the literature on online content creation on the other hand has shown that age is a decisive factor with young users producing more content online than older users socioeconomic status has a less clear effect highereducated and higherincome individuals are not necessary more likely to participate online 1 individual and sociodemographic factors however influence which specific social media platform people are more likely to participate in the user base of each platform is structured along age gender ethnicity income and education therefore digital traces on social media are not representative for the general population if this is not accounted for they will generate biased findings that overrepresent the experiences and opinions of a platforms prevalent sociodemographic group as this overview shows research on privacy management and participation is relevant for the advancement of digital inequality research however it does not specifically address digital footprints in fact digital footprints not only correspond to data produced through active online content creation but also depend on algorithmic operations and passive participation therefore there is a need to incorporate studies that do not explicitly align themselves with digital inequality scholarship to fully address the relevance of this new dimension what are digital footprints moving beyond online content creation digital footprints are not only the product of active participation through content production and sharing but they may also be generated by algorithms and by other internet users therefore they are the sum of the data produced both by active and passive forms of participation while active participation corresponds to online content creation passive participation is a new concept not fully explored within digital inequality scholarship our conceptualization of the term draws on casemajor et als definition passive participation is engaging in a platform while being subject to processes of decision that happen outside of ones control two types of passive participation can be distinguished data generated by platforms as a byproduct of users online behavior and data posted by other users but linked to an individual although discrimination is a crucial threat for both types of passively produced digital footprints different concerns arise for the two types for the first surveillance and deceiving targeted advertising are particularly relevant for the second harm in users reputation is more pertinent these concerns pertain to internet users from all socioeconomic backgrounds however it is still underinvestigated whether those with lower socioeconomic status are affected differently by their digital footprints digital footprints as a byproduct of users online behavior social media platforms afford many simple user actions such as liking favoriting following or commenting which are not seen as online content creation by most studies on internet use but contribute to digital footprints browsing histories search queries purchase histories and geolocation information are further types of sensitive data that even if hidden to users contribute to digital footprints platform algorithms have a pivotal function in generating such data they not only encourage users to provide personal data filling in profiles and forms but also generate digital traces from every action users perform online notably such data create value for social media companies thanks to data mining activities platforms and thirdparties analyze organize classify and make sense of such data for behavioral predictions surveillance and advertising digital footprints if accessible and analyzed with appropriate tools offer an extremely accurate profile of an internet user for example kosinski stillwell and graepel used facebook likes an easily accessible type of digital traces to predict personal attributes such as sociodemographics ethnicity sexual orientation religious and political views personality traits or use of addictive substances with great accuracy the digital footprints produced by users online behavior might have positive and negative repercussions for social inequalities since most of the data generation processes run automatically and in the background a first issue of concern is whether internet users are aware that platforms produce data from their microacts of online participation research has shown for example that many users are not even aware that facebook curates their news feed and tailors posts according to their previous behavior overall great differences exist in user awareness and perspectives on social media data mining attitudes vary along individual factors such as age and socioeconomic status as well as the various contexts and forms of tracking and monitoring for instance studies have found that while many young people use social media actively they are not particularly concerned about institutional privacy that is how companies and third parties will use their information another crucial issue concerns the unequal consequences of the data collected by platforms algorithmically generated data can be used by platforms to propose content that is more in line with a users interests but it can also enable discrimination online platforms collect user data to create profiles that are sold to advertisers and thirdparty companies this might increase the likelihood for underprivileged users to receive poorer or even fraudulent offers users are targeted by online advertising based on their digital footprints which has been shown to reproduce social and cultural distinctions in the domain of online advertising oneil recounts the case of us forprofit colleges investing considerable amounts of money in online ads targeted at poor and vulnerable people difficult life conditions as well as a lack of knowledge about the higher education system make them easier to persuade to pay high tuition fees for a diploma that eventually has little value in the job market to reach this specific population colleges use online search advertising platforms like google allow advertisers to segment users according to countless attributes deduced from their search queries and online behavior forprofit colleges the payday loan industry and many other sectors use digital trace analytics for price discrimination digital footprints as data produced by other users internet users can be participated by other users examples include tagging endorsements ratings and comments on the visible end of the spectrum and searches and various data analyses on the less visible end such forms of passive participation may produce both desirable and profitable consequences as well as unsolicited or annoying outcomes receiving ratings likes and shares may enhance someones status online the significance of data generated by other users is particularly evident for microcelebrities such as web influencers and youtubers in fact such skilled internet users constantly engage with their followers on several platforms with the purpose of receiving feedback microcelebrities are aware that their followers activities are fundamental for maintaining their popularity online the relevance of ratings and reviews is also vital for users of sharing economy platforms because both providers and consumers of sharing economy services largely rely on platforms rating systems users with greater knowledge of social media platforms are better able to tailor their messages to reach the targeted audience and to maximize their visibility online by doing so they often leverage social media algorithms to their own advantage receiving positive feedback from other users selfbranding intended as managing ones digital identity and improving the quality and quantity of data associated to ones profile is a new dimension of internet skills which has not been thoroughly investigated yet and may be associated with offline social inequalities data made available by other internet users could also be undesirable and problematic users manage their reputation not just through privacy settings and attentive posting but also by untagging controversial or unflattering photos deleting posts that depict them negatively and so on unwanted content posted to someones profile is an instance of othergenerated face threats although privacy protection is often framed as an individual responsibility both the social and technical contexts define what information is available about someone online users are made responsible for the behavior of people in their networks and this puts lowincome users in an especially difficult condition how to study digital footprints we argue that digital inequality research on digital footprints should combine different methodological approaches representative surveys could measure digital skills related to platform algorithms and privacy settings qualitative interviews combined with social media profile analysis could also be a valuable method during interviews respondents could discuss content they have posted but also what has been posted by others as well as by the platform itself moreover interviews could be enriched by search engine use so that respondents could look for their digital traces and discuss the results with the interviewer interviews with social groups particularly affected by digital traces could investigate how digital footprints are perceived and enacted young users and microcelebrities would be groups to scrutinize such actorfocused methods could inform social analytics how users reflect upon and adjust their online presence and the actions that feed into it through the use of analytics beyond this media content analyses of negative passive participation for example in the form of doxing and online harassment could help case study selection finally digital methods and software studies could offer useful insights to understand how platforms generate data with implications for digital inequalities this also includes the critical study of algorithms or how digital footprints influence reality construction and social order finally on a macrolevel content analyses and legal assessments of platform documents such as their terms and conditions and privacy policies could enhance our understanding of digital footprints for example the analysis could focus on whether such documents contain information on the protection of certain groups for example in terms of gender age or socioeconomic status conclusion in this article we introduced the notion of digital footprints as a new dimension of digital inequality we argued that previous digital inequality scholarship has failed to pay sufficient attention to users digital traces after introducing the initial concept of a digital footprint gap as the differences in the amount of online traces between individuals or population groups we discussed the role of active content creation algorithmically generated data as byproduct of user activity and of data posted by other users but linked to an individual the latter two forms present interesting avenues for digital inequalities scholarship as they challenge the notion of active internet use and agency when it comes to digital divides by considering algorithmic and othercreated digital footprints digital inequalities scholarship could venture into adjacent discourses and understand digital divides more holistically theoretically and in a more contextualized manner systematic investigations of digital footprints for example with methodologies we described in the previous section would also allow for practical recommendations particularly regarding inclusive platform design the development of buildings services devices and websites accessible to all citizens especially the elderly and disabled is widely acknowledged as a fundamental prerequisite for an inclusive society in the same vein online platforms should be designed not only to be accessible but also to prevent the occurrence of a digital footprint gap in particular underprivileged and underrepresented groups could be given more voice while those groups that are particularly vulnerable to harassment or exploitation through their digital footprints could be better protected simple and transparent alert mechanisms on social media are an example of design implementation in this regard as well as specific privacy enhancing technologies defined within the privacy by design sociotechnical approach digital footprints as an emerging dimension of digital inequality connect to the broader societal and academic discourse on the mutual dependencies of society and technology while digital inequality scholarship has addressed this nexus by analyzing the mechanisms between life chances and the purposeful use of icts we have argued for the inclusion of digital footprints in the analysis of what ultimately concerns informational and social justice

purposethis conceptual contribution is based on the observation that digital inequalities literature has not sufficiently considered digital footprints as an important social differentiator the purpose of the paper is to inspire current digital inequality frameworks to include this new dimension designmethodologyapproach literature on digital inequalities is combined with research on privacy big data and algorithms the focus on current findings from an interdisciplinary point of view allows for a synthesis of different perspectives and conceptual development of digital footprints as a new dimension of digital inequality findings digital footprints originate from active content creation passive participation and platformgenerated data the literature review shows how different social groups may experience systematic advantages or disadvantages based on their digital footprints a special emphasis should be on those at the margins for example users of low socioeconomic background originalityvalue by combining largely independent research fields the contribution opens new avenues for studying digital inequalities including innovative methodologies to do so

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introduction physical activity provides health benefits such as the reduction of cardiovascular risks 1 psychological benefits improved academic and cognitive achievement 2 and in cognitive functions in patients with cystic fibrosis 3 and mental 4 and social health benefits 5 the world health organization recommends at least 60 min of moderatetovigorous physical activity per day to achieve benefits 6 in this sense it is crucial to develop an active living style which means according to sallis including four domains of physical activity active recreation exercise active transport and household and occupational activities 7 therefore active commuting to and from school which is defined as walking or cycling to school would lead to increased physical activity in youth populations 8 in addition to the increase in physical activity acs improves physical fitness and wellbeing 9 despite all these benefits in recent decades acs has decreased worldwide 1011 and specifically in spain from 61 to 46 in adolescents 12 consequently it is necessary to reverse this trend to contribute to a healthier society in addition there are different factors that determine acs such as personal social and environmental factors 1314 in relation to the personal factors the preferential mode of commuting may influence the choice of the mode of commuting to school and specifically cycling to school 15 in addition other relevant factors reported as barriers to acs for children are social support or environmental factors such as traffic 16 on the other hand the parental barriers perceived about their childrens acs play an important role the perception of the distance between the house and school and the presence of dangerous intersections 1617 traffic and crimerelated safety 18 bullying and the possibility of abductions 1920 are perceived as barriers associated with the acs of their children these barriers differ by childrens age parental concerns over childrens safety are higher in younger children and should be reduced when they move to adolescence so they have more freedom to commute between school and home independent of adult supervision 21 a study in seattle identified that the design of the neighborhoods and parental concerns were significantly associated with childrens acs 22 so it will be important to know what parental perceptions are associated with acs consequently there is evidence about the association of parent s and children s barriers with the children s acs however few studies compared the barriers of parents and children towards active commuting tofrom school to have a more global overview and take these factors into account which may be more relevant to implement future and effective interventions to promote acs a study in washington dc with a sample of 193 children and their parents found that the parents confidence in their childrens walking or bicycling to school was much greater than the childrens confidence ratings 23 lastly a study from gent analyzed the differences in barrier perceptions and their relationship with independent mobility and parents reported a more negative perception of traffic and crimerelated safety than their adolescents moreover the parents perception was more strongly associated with independent mobility than the adolescents perceptions 24 consequently the aims of this study were to compare the barriers to active commuting to and from school between children and their parents separately for children and adolescents and to analyze the association between acs and the childrens and parents barriers reported by a questionnaire separately for children and adolescents 25 26 27 materials and methods study design and participants this is a crosssectional study with child and parental participation the data were collected between march of 2018 and march of 2020 as part of the pedalea y anda al colecycle and walk to school study the paco study analyzes the determinants and correlates of acs and examines the effects of a schoolbased cycling intervention on adolescents cycling to school as well as on physical activity in the current study we focus on the correlates of acs based on childrens and parents perceived barriers to acs participants were selected in two cohorts one public secondary school and one public primary school from the city of alhendín selected by convenience ten public secondary schools from four cities granada jaén toledo and valencia which were randomly selected the procedure in the 1st cohort started with contacting the schools of alhendín and having meetings with the school board teams to inform them about the project then after the school accepted the participation in the project parents signed the informed consents to participate the procedure in the 2nd cohort started by randomly selecting 10 secondary schools from the overall public secondary schools from four spanish cities once the school was selected the research staff contacted the school board team to arrange a meeting and explain the project after the school accepted the participation parents signed the informed consents to participate a total of 600 childparent pairs were invited to participate in this study and 401 children and their parents completed the questionnairesonly those childparent pairs where both completed the questionnaire were included the ethics committee of the university of granada approved the study design study protocols and informed consent procedure measurements 221 sociodemographic characteristics parents selfreported their gender age educational level and socioeconomic status the educational level was categorized as nonuniversity or university the socioeconomic status was categorized as low when the parents selected answers from none eur 5000 mode of commuting tofrom school the mode of commuting was extracted from the valid and reliable mode and frequency of commuting to and from school questionnaire 2527 that was filled by children during their school schedule under supervision of the research team the aim of the questionnaire is to determine the mode of commuting of children tofrom school the questions were how do you usually get to school and how do you usually get home from school and the possible answers were walking cycling car motorbike scholar bus public bus metrotrain or other only one option could be chosen children and adolescents were categorized as active if they reported walking or cycling as their mode of commuting and as passive if they answered car motorbike scholar bus public bus metrotrain children s perceived barriers the childrens perceived barriers to acs were assessed using the questionnaire barreras en el transporte activo al centro educativo which has been validated in spanish adolescents 2829 this questionnaire elicited information on barriers and perceptions of children go tofrom school though a question and 18 items which refer to environmental safety autonomy or relatedness among others the participants had to rate how strongly they agreed with each statement through a likert scale of 4 points this scale showed a good internal consistency for the subscale of environmentsecurity barriers and for the planningpsychosocial barriers in the same way active commuting to school was related to the total scale environmentsecurity barriers and planningpsychosocial barriers 29 parents perceived barriers the parental perceived barriers to acs were assessed using the parental perception of barriers towards active commuting to school which has been validated in spanish children and adolescents 26 the question was formulated in this way here are some situations that might occur on a daytoday basis for each situation please indicate how much you agree or disagree that it might affect your decision not to allow your child to walkbike to or from school the scale includes 23 different items categorized as general barriers including those common to both walking and cycling to school walking barriers including those referring to walking and cycling barriers including those referring to cycling the scale asked the participants to rate how strongly they agreed with each statement through a likert scale of 4 points this scale showed a good internal consistency for the overall question and for the three scales the intraclass correlation values were moderate the overall scale and the general and walking barrier scales showed a moderate to high validity to predict active modes of commuting 26 comparison procedure of childrens and parents barriers in order to be able to compare the childrens and parents barriers coming from the batace and pabacs questionnaires respectively the barriers to acs were clustered into categories these categories were proposed according to the scientific literature in a recent previous systematic review 30 following this categorization we set 13 common barriers for both children and parents to offer a common framework and be able to compare them these 13 common barriers are grouped on the basis of general situations walking situations and cycling situations statistical analysis the descriptive data of the participants are presented as frequencies for categorical variables and mean and standard deviation for continuous variables a kolmogorovsmirnov test was conducted to analyze the distribution and the results followed the normal distribution differences between age were calculated using a students ttest for continuous variables and chisquare test for categorical variables the internal consistency of barrier categories was checked by cronbachs alpha to analyze the mean difference between children and their parents and between adolescents and their parents a ttest for independent samples was conducted to establish the association between commuting to school and the barriers several binary logistic regressions were performed the mode of commuting was established as the dependent variable and each barrier was separately established as an independent variable consequently a separate binary logistic regression was implemented for each barrier all the analyses were performed with the statistical package spss for windows version 23 establishing a level of statistical significance of p 005 results the descriptive data of participants and the differences between children and adolescents are presented in table 2 the mean age of children was 1326 ± 178 years old and the mean age of parents was 4435 ± 554 years old the childrens mode of commuting tofrom school was mostly active and the parents mode of commuting to work was mainly passive additionally the educational level of parents was mainly nonuniversity and the socioeconomic status was low the internal consistency showed cronbachs alpha values of 0844 for general barriers 0489 for walking barriers and 0524 for cycling barriers data in bold significant changes pvalue 005 the table 3 shows the parental barrier differences between children and parents by age group the perception of barriers was different between childrenadolescents and parents except for social support for both of them and physical and motivational barriers in children the parents reported higher importance for distance traffic convenience built environment crimerelated safety and weather than children and adolescents whereas the childrenadolescents reported higher importance of physical and motivational barriers and social support than parents the results of table 4 present the association between acs and the barriers in children when they reported higher importance for the distance between home and school traffic safety convenience and built environment the odds of actively commuting to school were lower in relation to the parents of children when they reported higher importance for distance traffic safety and convenience the odds of actively commuting to school were lower in adolescents the odds of actively commuting to school were lower when they reported higher importance for distance traffic safety convenience built environment crimerelated safety weather built environment and built environment in relation to the parents of adolescents the odds of actively commuting to school were lower when the they reported higher importance for distance traffic safety convenience built environment physical and motivational and physical and motivational discussion the main findings of this study were 1 the most important barriers to acs for children and adolescents were physical and motivational and social support barriers by contrast the most important barriers to their childrens acs according to parents are the distance between home and school traffic safety convenience built environment crimerelated safety and weather 2 the acs rates were lower when the childrenadolescents and their parents reported higher perceived barriers to acs the children and adolescents perceived more importance of the physical and motivational and social support barriers than their parents the findings suggested that these groups of populations need physical or motivational encouragement to walk or cycle to school similarly a study carried out in australia found that different factors such as social support may influence childrens acs 31 another study in the usa with adolescents reported that the absence of other children to walk with was related to acs 28 consequently the findings showed that it is more important for children and adolescents to have somebody to walk or cycle to school with than for the parents timperio et al 31 highlight that having other children nearby may be important in all the strategies for increasing active commuting to school 31 it is especially important when children grow because they become the decision maker of their mode of commuting finally this higher importance for the children may be related to a greater importance of socialization for children and adolescents 32 the parents showed greater concerns than children about the distance traffic safety convenience built environment crimerelated safety and weather in this sense greves et al 20 found that parents and grandparents of children from 6 to 13 years old present crimerelated safety distance built environment and weather as barriers to acs of their children 20 the same results were found in the studies of carlson et al 21 and hume et al 33 where the barriers of traffic safety and the built environment were perceived by parents of children and adolescents 17 parents would be more realistic about the barriers related to the natural and built environment as well as the traffic and the safety issues due to their greater experience because the acs is a habit which is a representation of stimulusresponse links and they are in a sense directly elicited by the environmental states or stimuli or contexts 34 there are several childadolescent and parental barriers associated with acs according to the results of our study the barriers of distance traffic safety convenience and the built environment are associated with acs both for children and adolescents and their parents several studies confirm that the barriers such as distance traffic safety convenience or the built environment are associated with acs 30 the barrier of distance is the main barrier associated with acs 35 and is a predictor of the mode choice among adolescents 36 regarding the convenience barrier a study carried out in texas with 857 parents of children declared convenience as a barrier to active commuting to school of their children 37 additionally the study of timperio et al 31 found the physical neighborhood environment to be a factor of influence on acs so the improvement of urban design could be a strategy for increasing acs finally the traffic safety barrier is associated with acs because of the speed of traffic on the route to school the amount of traffic the safety at intersections crossing problems or the availability of crossing guards concern this population on the way to and from school 38 in addition to the barriers mentioned in the previous paragraph when the adolescents perceived crimerelated safety and weather as barriers acs was lower crimerelated safety is a barrier for adolescents even more for boys than girls in their neighborhood 39 our study presented similar results to the study of forman et al 28 carried out in usa where the barrier of crimerelated safety was associated with acs or the weather barrier as the weather barrier could be affected by the location in spain the main problem is the heat as in the study of herradorcolmenero et al 40 where the participants of this study perceived the weather as a barrier to commuting meanwhile in other areas such as the northern united states or canada extreme winter conditions are one of the main barriers associated with active commuting to school 22 the results of our study showed the necessity of working with the perceptions of schoolchildren and parents in order to increase acs it is very important to develop interventions related to the specific contexts as barriers for parents of children and parents of adolescents are similar but not the same 17 and consequently interventions in school and high school may differ in addition strategies to improve the built environment infrastructure are necessary to encourage the behavior change the perceptions of barriers of children and adolescents are susceptible to change as is the mode of commuting to school 41 consequently the design of interventions and programs to promote acs must be done with the objective of increasing the awareness in youth and their parents and increasing the support for this behavior with regard to both parents and childrens similar perceived barriers so reducing the perception of barriers will be necessary to design practical strategies such as providing educational sessions where students learn what type of backpacks are best and least harmful for carrying weight or educational sessions about this behavior where students can learn the shortand longterm benefits of commuting actively additionally another strategy could be the design and implementation of road safety education courses for students to learn how to get around safely by walking and cycling so that parents may reduce their perception of barriers in addition increasing the rates of children who actively commute to school will be important to minimize the impact of noise exposure 4243 in our study some limitations can be pointed out firstly although in this study there is a great geographic diversity within the same country we cannot generalize the results because the sample was recruited only in spain it is necessary to highlight as strengths of this study that the sample of the study is a mixture of convenience and randomization samples and it was taken in two cohorts additionally validated and reliable tools were used and a large population of child and parent pairs participated in this study finally this is the first study that has compared the childadolescent and parental barriers to our knowledge conclusions in conclusion the children and adolescents perceived higher physical motivational and social support barriers to acs than their parents the parents perceived a higher importance of distance traffic safety convenience built environment crimerelated safety and weather than their childrenadolescents the distance between home and school convenience traffic safety crimerelated safety and built environment perceived by the children adolescents and the parents were associated with a lower rate of acs in addition when adolescents perceived crimerelated safety and weather barriers the rate of acs was also lower therefore it is necessary to design specific interventions that include both populations and focus on the most important barriers that they perceived towards acs to this end it would be important that policy makers administrations and schools provide the necessary support to implement such interventions funding this study was supported by the spanish ministry of economy industry and competitiveness and the european regional development fund additionally this study took place thanks to funding from the university of granada plan propio de investigación 2016 excellence actions units of excellence unit of excellence on exercise and health and by the junta de andalucía consejeria de conocimiento investigación y universidades and european regional development fund 44 r d research staff contract within the framework of the spanish national youth guarantee was also funded by the junta de andalucía and the european social fund institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the ethics committee of the university of granada informed consent statement informed consent was obtained from all subjects involved in the study data availability statement the data will be available on request

the main objectives of this study were to compare the barriers to active commuting to and from school acs between children and their parents separately for children and adolescents and to analyze the association between acs and the childrens and parents barriers a total of 401 childparent pairs from granada jaén toledo and valencia selfreported separately their mode of commuting to school and work respectively and the childrens barriers to acs ttests and chisquare tests were used to analyze the differences by age for continuous and categorical variables respectively binary logistic regressions were performed to study the association between acs barriers of children and parents and acs both children and adolescents perceived higher physical and motivational barriers and social support barriers towards acs than their parents all p 005 additionally the parents perceived higher distance traffic safety convenience built environment crimerelated safety and weather as barriers towards acs than their children all p 005 moreover a higher perception of barriers was related to lower acs the results of our study showed the necessity of attenuating the perceptions of children and their parents in order to increase acs this is relevant to develop interventions in the specific contexts of each barrier and involving both populations

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introduction throughout the twentieth century western european societies have witnessed a considerable increase in educational levels over the same period religious affiliation and religious participation have declined the netherlands is a leading country in educational expansion and secularization since the second half of the twentieth century the educational level of the dutch has risen substantially which coincided with a strong decline in religious affiliation church attendance and traditional christian beliefs previous research consistently found higher educated individuals to show less ethnic prejudice compared to lower educated also nonreligiously affiliated people and people who do not attend church were found less prejudiced than church members and regular churchgoers thus education religious affiliation and attendance are statistically related to ethnic prejudice at the individual level while the shares of highly educated and nonreligious individuals have increased consequently one would expect a longitudinal decline in prejudice at the national level in contrast levels of ethnic prejudice seem to have risen in the netherlands several scholars found more widespread support for ethnic discrimination in the housing and labor markets since the late 1980s and stronger support for ethnic prejudice since the 1990s similar changes have been found in other european countries for an overview for example semyonov et al found a rise in antiforeigner sentiment between 1988 and 2000 in 12 european countries other studies showed considerable differences between european countries in the direction and magnitude of changes in antiimmigrant and antiimmigration attitudes since 2000 with attitudes recently becoming somewhat less negative in several countries including among others the netherlands germany and poland although there are indications that dutch public opinions on ethnic diversity have recently become milder the documented rise in ethnic prejudice over the past decades gives rise to a puzzling paradox while the shares of higher educated people and nonaffiliated people in dutch societyknown for their relatively lower levels of prejudicehave increased over time prejudice against ethnic outgroups has yet increased there are two possible explanations for this first ethnic prejudice may have risen to such a degree throughout society that it has offset the impact of educational expansion and secularization in this scenario the levels of ethic prejudice within all categories of education and religious affiliation have risen to the same extent second the levels of ethnic prejudice may have risen particularly within the higher educated and the nonaffiliated as a consequence educational expansion and secularization could then not have reduced prejudice in society few studies however have examined whether the relationship of education and religious affiliation with prejudice has changed over time and the results are mixed for example quillian and jaspers showed that the effect of education increased over time in the us and in the netherlands whereas easterbrook et al found stable relationships between education and antiimmigrant attitudes over time based on british and international surveys in their metaanalysis hall et al found decreasing associations between extrinsic religiosity and ethnic prejudice over time while jaspers found no changes in the effect of church membership over time in the netherlands in addition if the relationship of education and religious affiliation with ethnic prejudice has indeed changed it remains unclear which educational and religiously affiliated groups are responsible for these changes by expressing more or less ethnic prejudice over time in a dutch study de lange et al found a widening gap in ethnic threat between higher and lower educated caused by a stronger increase among the latter however the authors only considered linear trends we therefore examine whether the levels of ethic prejudice within categories of education church membership and church attendance have changed over time at any rate most importantly it remains unknown to what extent these changes in the levels of ethic prejudice can explain the longitudinal rise in ethnic prejudice despite educational expansion and secularization although few studies considered the effect of changing levels of prejudice within particular groups none of these studies took distributional shifts of these groups into account which may have resulted in biased effects to overcome this we use counterfactual analyses we examine whether the rise in ethnic prejudice is still present if the levels of ethic prejudice within categories of education and religious affiliation would not have changed over time while controlling for distributional shifts ie educational expansion and secularization this leads to the following research questions a have the higher educated and the nonaffiliated become more prejudiced than others between 1985 and 2011 b if so to what extent have these changes contributed to the observed rise in prejudice in the netherlands between 1985 and 2011 while taking into account educational expansion and secularization rising levels of ethnic prejudice may have detrimental consequences for interethnic relations in society ethnic prejudice may lead to negative intergroup behavior such as discrimination exclusion or hostility feelings of exclusion and discrimination may hamper ethnic minorities social integration and increase withdrawal into ones own ethnic group which could eventually result in radicalization or criminalization understanding to what extent the rise in ethnic prejudice can be explained by certain groups in society expressing more prejudice over time may inform policies to reduce interethnic tensions theories and hypotheses ethnic competition theory on the individual level ethnic competition theory has proven fruitful to explain differences in ethnic prejudice between the higher and lower educated and between nonreligious and religiously affiliated individuals competition between ingroup members and ethnic outgroup members over scarce economic or cultural resources poses a real threat to the social position of the ingroup as a whole and in particular to those competing more severely with ethnic outgroups this encourages perceptions of interethnic threat which in turn induce ethnic prejudice and exclusionism in general ethnic minorities have more disadvantaged socioeconomic positions and less education compared to the average population natives with lower education are more likely to hold similar economic positions to ethnic minorities than higher educated natives lower educated natives may therefore have stronger perceptions of threat from ethnic minorities over economic resources such as jobs and social security benefits than higher educated individuals which induces prejudice against ethnic minorities higher educated individuals may perceive less ethnic threat because they compete less with ethnic minorities but also because they are less susceptible to ethnic threat it is argued that education increases awareness to alternative viewpoints and broadens peoples perspectives including ideas of cultural relativity and diversity as a consequence higher educated individuals will be better able to recognize cultural expressions and more willing to accept cultural and ethnic differences likewise the educational system is argued to transmit democratic norms and values that emphasize individual and cultural freedom and enables pupils to generalize these principles to minority groups the higher peoples educational level the longer their exposure to this liberalizing influence of education and the less ethnic prejudice they have competition between dutch natives and ethnic minorities may also concern cultural resources that is belief systems and dominant cultural norms and values ethnic minorities often have different cultural norms and values and belong to nonchristian religions or are perceived as such by dutch natives consequently these conflicting values may be perceived as a threat to the central values of the ingroup which could evoke prejudice against any ethnic outgroup religiously affiliated natives may perceive ethnic minorities beliefs as a threat to their own religious beliefs and practices which induces higher levels of prejudice among the religiously affiliated than among nonaffiliated people changing levels of ethnic prejudice education according to ethnic competition theory actual economic competition increases perceptions of ethnic threat in particular among those who are in similar socioeconomic positions as most members of ethnic outgroups during the second half of the twentieth century the number of low educated unskilled migrants has increased in the netherlands and the established minority groups maintained a disadvantaged socioeconomic position compared to dutch natives consequently ethnic competition has increased among lower educated individuals in particular which could have induced higher levels of ethnic prejudice among the lower educated in addition modernization has considerably improved educational opportunities for children from lower socioeconomic backgrounds as a result the group of lowest educated people in dutch society has become smaller and more homogeneous with fewer cognitive financial and social resources and less cultural capital following the losers of modernization thesis the lowest educated categories in society lack sufficient cultural capital to get ahead in a rapidly changing world and find themselves in an increasingly vulnerable and isolated social position as a result lower educated individuals may have become more susceptible to perceptions of ethnic threat inducing higher levels of ethnic prejudice among these individuals both perspectives predict that the average level of prejudice has risen because the lower educatedwho already held more ethnic prejudicehave become even more prejudiced than before we hypothesize that particularly lower educated people have become more prejudiced over time which consequently increased the general level of ethnic prejudice in the netherlands although the established minority groups in the netherlands still have a disadvantaged socioeconomic position compared to the native majority their educational level and participation in senior or academic level occupations have improved over the past decades following ethnic competition theory middle and higher educated natives may therefore have increasingly perceived economic threat from ethnic outgroups inducing higher levels of ethnic prejudice among these categories lancee and sarrasin for example found that higher educated individuals in switzerland show more negative attitudes towards immigrants once they enter the labor market on which they compete with ethnic minorities moreover increased educational opportunities due to modernization have likely resulted in a more heterogeneous group of higher educated individuals with more variation in parental background cognitive abilities and cultural capital although scholars have demonstrated the importance of the educational system on reducing peoples ethnic prejudice others also found that part of the educational effect originates from differences in cultural capital or even from factors that influence peoples level of ethnic prejudice before they attend secondary education such as authoritarianism the heterogenization of higher education may therefore imply that people who are more susceptible to ethnic threat have increasingly attained higher educational levels as a result higher educated individuals as a group may have become more prejudiced over time thereby reducing the liberalizing effect of educational expansion based on these arguments we expect that the higher educated have converged towards the already prejudiced lower educated over time which consequently increased the general level of ethnic prejudice in the netherlands changing levels of ethnic prejudice church membership and attendance following ethnic competition theory strong identification with a religious group as well as the belief that ones religion is the only true religion increase competition with outgroup members from different religions due to immigration of in particular nonchristian migrants cultural and religious diversity have increased considerably in the netherlands the percentage muslims as part of the dutch population has risen from 04 in 1971 to 5 in 2012 hence over time christian natives have likely perceived increasing threat from ethnic minorities belonging to other religions especially in a secularizing country as the netherlands as a consequence people affiliated to christian churches may have become more inclined to preserve their religious identity by stressing the boundaries between the christian religious ingroup and other outgroups increasing their levels of ethnic prejudice based on these arguments church members and regular churchgoers may have become even more prejudiced over time thus we expect that particularly church members and regular churchgoers have become more prejudiced over time which consequently increased the general level of ethnic prejudice in the netherlands on the contrary the increased salience of cultural and religious threat posed by ethnic minorities may have also affected the nonaffiliated part of the dutch population due to modernization and individualization the significance of traditional christian norms and values has diminished over the past decades at the same time the increasingly secular dutch population is confronted with rising numbers of ethnic minorities belonging to nonchristian religions hence the debate on ethnic minorities has become centered around value conflicts ethnic minorities have often been framed as undermining liberal and democratic dutch values such as gender equality and tolerance towards homosexuals which are particularly cherished by the secular part of the population it is argued that secular natives want to defend their liberal values against the perceived moral conservatism of ethnic minorities religions this could have induced higher levels of prejudice among the nonaffiliated in particular thereby reducing the positive effect of secularization we therefore hypothesize that nonchurch members and nonchurchgoers have converged towards the already prejudiced religiously affiliated over time which consequently increased the general level of ethnic prejudice in the netherlands data and methods data to test our hypotheses we used data from the sociocultural developments in the netherlands surveys between 1979 and 2011 seven crosssectional waves were conducted with each successive wave being a replication and extension of the previous waves the methodological design of the repeated crosssections has remained largely similar and comparable over time each survey consists of a representative sample of the dutch population between 18 and 70 years and contains questions on a wide variety of social issues derived from previously tested valid and reliable measurements we used the surveys of 1985 1995 2000 2005 and 2011 which were combined into one pooled dataset the surveys of 1979 and 1990 were excluded because comparable measures on ethnic prejudice were missing questions measuring ethnic prejudice were administered solely to respondents whose nationality and that of their parents and grandparents therefore our study only includes native dutch individuals measurements dependent variable to measure ethnic prejudice respondents were presented five statements indicating prejudice against ethnic outgroups with moroccans you never know for certain whether they are going to be aggressive or not most people from surinam work quite slowly gypsies are never to be trusted turks are backward and when you do business with jews you have to be extra careful these statements are based on common stereotypes about moroccans turks and surinamese which are members of the three largest outgroups in the netherlands and gypsies and jews which had often been the object of prejudice and derogation in the past the items are a selection of a wider range of similar items which were previously tested and often used to measure prejudice against ethnic minorities response categories on each statement ranged from agree entirely to do not agree at all constituting a fivepoint likertscale the response category never thought about was excluded from analysis in 1985 and 1995 the five questions on ethnic prejudice were filled out by a random subsample of the total sample in these waves resulting in a total sample size of 5530 respondents to further limit the loss of cases on the dependent variable due to missing answers we conducted multiple imputation of missing values in spss for respondents with a valid answer on at least three of the five items respondents with missing answers on more than two of the five items were excluded from the analyses five sets of imputed values were independently drawn which were combined into one pooled set on which the analyses were performed after imputation 5229 respondents with a valid answer were left factor analysis of the five items indicated that the items refer to one single underlying dimension1 separate factor analyses per wave showed acceptable factor loadings and communalities which were comparable across the surveys factor scores were computed representing the weighted linear combination of the five items 2 we subtracted the minimum value from the factor scores to have the dependent variable starting at zero a higher score on the scale indicates more ethnic prejudice independent variables educational attainment was measured as the respondents highest education completed after elementary school response categories were recoded into seven categories ranging from primary education to masters or equivalent level and higher responses on the other category were treated as missing values and excluded from analysis between 1985 and 2011 the relative share of lower educated individuals decreased significantly from 143 to 28 for people with only primary education while the relative share of highly educated individuals increased significantly from 35 to 114 for people holding a masters degree or equivalent to measure religious affiliation we used both church membership and church attendance respondents were first asked whether they considered themselves a member of a church or religious community next respondents who answered yes were asked which church or religious community they considered themselves a member of we combined these questions into one variable indicating church membership and reduced the response categories to catholic protestant other christian nonchristian and nonmember we excluded individuals belonging to other christian and nonchristian religions because of their marginal numbers in the sample and because secularization mainly concerns the catholic and protestant churches in the netherlands church attendance was measured by a question on the frequency at which one attends services of a church or religious community about once a week about once a month once or twice a year or hardly evernever respondents who had no valid answer on the variable for church attendance were excluded from analysis between 1985 and 2011 the relative share of people considering themselves nonreligious increased significantly from 473 to 683 the percentage hardly ever or never attending services of a church or religious community increased significantly from 431 in 1985 to 583 in 2011 control variables birth cohort sex socioeconomic position degree of urbanization and province were included as control variables in the analyses as these characteristics are shown to be related to the dependent variable and could possibly confound the relation of education church membership and church attendance with prejudice 3 birth cohort was derived from the respondents birth year a linearity test indicated that we could include birth cohort linearly in the analyses without significant loss of explanatory power sex was measured as male or female to obtain one measure for socioeconomic position the egp classification of social class and main activity of the respondent were combined degree of urbanization was based on a measure of address density per square kilometer provided by statistics netherlands divided in five categories 4 province was measured as which of the twelve dutch provinces the respondent was living in at the time of the interview to control for possible nonlinear relations between the dependent variable and the independent variables dummy variables were created for each category of our individual and control characteristics except for birth cohort missing values on the independent and control variables were deleted listwise resulting in a sample size of 4780 respondents in our analyses see table 1 for descriptive statistics for all variables in the analysis method to investigate whether and how prejudice has changed over time within the different categories of educational attainment church membership and church attendance we used multivariate ols regression models to account for nonlinear changes we performed these analyses for each survey year separately next we calculated mean levels of prejudice for each category of educational attainment church membership and church attendance while controlling for all relevant variables secondly we examined the relative contribution of these changes to the observed trend in prejudice in a counterfactual simulation analysis we simulated the trend in prejudice as if the differential changes in prejudice within each category of education church membership and attendance had not taken place since 1985 we chose 1985 as a reference point because educational expansion and secularization were on their lowest in the period under study we used the predicted levels of prejudice in 1985 within all categories of education church membership and church attendance as found in the multivariate regression models to estimate a new mean level of prejudice in each subsequent survey year while taking into account the rising shares of higher educated and nonreligious individuals the differences between the observed and the simulated trends in prejudice show to what extent the observed trend is due to differential changes in prejudice within categories of education church membership and church attendance between 1985 and 2011 see appendix 3 for an explanation of this counterfactual simulation method using a straightforward bivariate example for two survey years 4 results general and differential trends in prejudice figure 1 shows the general trend in ethnic prejudice over time we observe a significant increase in prejudice against ethnic minorities from 116 in 1985 to 189 in 2011 5between 1995 and 2000 and between 2005 and 2011 the change in ethnic prejudice was not significant 6table 2 shows the associations of education church membership and church attendance with ethnic prejudice per survey year based on multivariate ols regression analyses for ease of interpretation we transformed the regression coefficients such that the intercept represents the weighted mean level of prejudice in each year while the dummy variable coefficients reflect the deviance from this overall sample mean in line with previous research table 2 shows a positive relationship of educational attainment with prejudice in each survey year lower educated individuals held significantly more prejudice than average while the higher educated held significantly less prejudice than average in 1985 for example the mean level of prejudice among people with primary education lies 038 points above the average of 159 people with masters or equivalent level show a prejudice level that lies 060 points below the average of 159 the standardized coefficient shows a considerable impact of education which seems to have slightly decreased over time the influence of church membership and church attendance to analyze whether and how ethnic prejudice has changed over time within categories of education church membership and church attendance we calculated the controlled estimated mean levels of prejudice for each category which are presented in table 3 to test whether the mean level of prejudice in each category has changed significantly between two subsequent survey years we used a statistical test for the difference between two regression coefficients across independent samples as suggested by paternoster et al table 3 shows that the trend in ethnic prejudice developed differently within each category of educational attainment between 1985 and 1995 particularly higher educated people became more prejudiced as their mean level of prejudice rose significantly from 099 to 144 consequently higher educated individuals converged towards the lower and middle educated the last column of table 3 shows the increase in prejudice between 1985 and 2011 which was stronger among the higher educational levels and weaker among people with vocational training the strongest increase is found among people with a masters degree or equivalent level this can also be seen in fig 2 in which we visualized the changes in ethnic prejudice among the lowest middle and highest educated individuals table 3 also shows significant increases in prejudice among protestants nonmembers and monthly churchgoers between 1985 and 1995 and among nonmembers and weekly churchgoers between 2000 and 2005 yet the last column of table 3 shows that the overall increase in prejudice between 1985 and 2011 was strongest among catholics and weekly churchgoers by which they diverged from the mean level of ethnic prejudice survey year fig 1 the trend in ethnic prejudice in the netherlands 19852011 note filled marker indicates significant mean difference compared to previous survey year grey area shows the 95 confidence interval source socon 19852011 table 2 regression coefficients of educational attainment church membership and church attendance on ethnic prejudice expressed as the deviance from the sample mean in each survey year source socon 19852011 1985 to obtain a standardized coefficient which summarizes the effect of the dummy variables we calculated a sheafcoefficient for each set of dummy variables average prejudice level notwithstanding the differences in prejudice levels between these groups remain very small counterfactual analyses to this point we have found a considerable change in levels of prejudice among the categories of educational attainment while the changes within the categories of church membership and church attendance were limited although prejudice on average rose significantly across all of these groups in society between 1985 and 2011 we found stronger increases among higher educated individuals catholics and weekly churchgoers to test whether these differential changes have contributed significantly to the observed overall increase in prejudice we used the outcomes of the multivariate regression analyses from table 3 in a series of counterfactual simulations figure 3 graphically presents the observed trend in prejudice and the simulated trends resulting from simulations for which we held the levels of prejudice within each category of educational attainment church membership and church attendance constant on the 1985 level while taking into account the shifts in the distribution of these categories within the sample the socon 19852011 14 socon 19852011 exact differences between the observed and simulated means and the corresponding bootstrapped confidence intervals are shown in table 4 8 in fig 3 the horizontal baseline represents a simulated nullmodel with no change in the levels of prejudice within categories of education church membership and church attendance and no shift in the distribution of these characteristics since 1985 the exact differences between the flat baseline and the actual observed trend are shown in table 4 row the corresponding confidence intervals all indicate that the observed means differ significantly from the baseline mean in each survey year to illustrate the difference between the 1985 baseline mean and the observed mean in 2011 is 030 the corresponding bootstrapped 95 confidence interval for this difference indicates that the true difference in the population is to be found between 026 and 033 next we simulated a new mean level of prejudice in each survey year for which only the levels of prejudice within education were held constant on the 1985 level whereas all other levels as well as the sample distributions of all variables varied across subsequent years line in fig 3 shows the resulting simulated trend as previously demonstrated the three highest educational levels showed a stronger increase in their mean levels of prejudice between 1985 and 1995 than the other educational categories consequently these categories converged towards the average level of prejudice in table 4 row shows that if levels of prejudice within these educational table 4 estimated differences between baselineobserved religiositybaseline and educationbaseline and bootstrapped 95 confidence intervals source socon 19852011 8 the sampling distribution of the differences between the observed and the simulated means is unknown and depends on the estimated and simulated effects on the observed distributions and the covariances between all variables therefore we used a bootstrapping procedure to empirically determine the shape of the sample distribution for each estimated difference in table 4 for each survey year we drew 25000 bootstrap samples with replacement from the original sample based on these samples we could determine the lower and upper boundaries of the 95 confidence interval to test the significance of the difference between the observed means and our simulated means for instance the difference between the total simulated mean in 2011 and the baseline mean which amounts to 015 will most likely lie somewhere between 016 and 013 in the target population the paradox of rising ethnic prejudice in times of… 667 categories had not changed since 1985 the overall level of prejudice would have significantly decreased with 007 points compared to the baseline which reflects the counterfactual situation in which everyone would have had the overall 1985 level of prejudice any difference between this baseline and line reflects differential changes in levels of prejudice within the categories of education in addition prejudice rose strongly among lower educated individuals between 2000 and 2011 who consequently moved further away from the average level of prejudice row of table 4 shows that the simulated trend continues to decline if these changes had not taken place and that this decline is significant in each survey year to illustrate the simulated mean prejudice level in 2011 would lie 012 points below the baseline the corresponding confidence interval indicates that the true decline in the mean level of prejudice in the population probably lies somewhere between 010 and 013 thus the stronger rises among higher educated and lower educated people have both contributed to the observed trend in ethnic prejudice in the netherlands over and above the general rise in the average prejudice level if these changes within the educational groups had not taken place the rising proportion of higher educated people in the netherlands would have resulted in a longitudinal decline in the mean level of prejudice in society this supports hypothesis 1a and hypothesis 1b for period 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 line in fig 3 shows the simulated trend for a situation in which only the levels of prejudice within categories of church membership with prejudice were held constant on the 1985 level whereas all other levels as well as all distributions could vary across the survey years we found little influence of church membership on ethnic prejudice consequently line shows a minimal decline in the mean level of prejudice between 1985 and 2011 in row of table 4 for example the simulated mean in 2011 would have been 003 points lower compared to the baseline the corresponding confidence interval indicates that the true decline in the mean level of prejudice in the population probably lies somewhere between 002 and 004 row of table 4 also shows that the differences between the baseline and the simulated means with constant levels for church membership in each survey year are significant though very small thus the rise in ethnic prejudice between 1985 and 2011 among catholic church members and to a lesser extent among nonmembers has contributed for a very small part to the observed trend supporting both hypothesis 2a and 2c line in fig 3 demonstrates the simulated trend in prejudice for which we held only the prejudice levels within categories of church attendance constant on the 1985 level in the previous section we found little influence of church attendance on ethnic prejudice as a consequence the simulated trend for which the rising shares of nonchurchgoers are taken into account hardly deviates from the baseline this is confirmed by row of table 4 which shows no significant differences between the baseline means and the simulated means with constant levels for church attendance therefore there is no support for hypothesis 2b and hypothesis 2d the separate contributions of differential changes in levels of ethnic prejudice within the various levels of educational attainment church membership and church attendance add up to the total simulated trend in fig 3 if these levels are all held constant since 1985 the average level of prejudice would have declined between 1985 and2011 table 4 row shows that this decline amounts to 015 points below the baseline by 2011 and probably lies between 013 and 016 in the population the confidence intervals in row of table 4 indicate that the difference between the total simulated means and the baseline is significant in each survey year this study was aimed at providing insights into the paradox of increasing shares of highly educated and nonreligious individuals in dutch societycategories which generally hold less prejudiceon the one hand and yet on the other hand a longitudinal rise in ethnic prejudice in the netherlands based on ethnic competition theory we formulated hypotheses on differential changes in prejudice within specific educational and religiously affiliated groups in dutch society that could explain the observed rise in ethnic prejudice despite educational expansion and secularization we added to previous research by testing the unique contribution of these differential changes to the observed trend in ethnic prejudice while controlling for shifts in the distribution of these characteristics for this purpose we used five nationally representative crosssectional surveys collected between 1985 and 2011 in counter factual analyses in line with prior studies we found that lower educated people held significantly more and higher educated people significantly less prejudice than average while the average level of prejudice rose significantly between 1985 and 2011 across all educational categories in society the increase was stronger among the higher educated who thus converged towards the average level of prejudice particularly between 1985 and 1995 this stronger increase in ethnic prejudice among higher educated individuals in particular could partially explain why an overall rise in ethnic prejudice is observed despite educational expansion we further found a weak and largely nonsignificant influence of church membership and church attendance on prejudice although catholics and weekly churchgoers showed a stronger increase in ethnic prejudice as compared to protestants nonchurch members and people less frequently or never attending church differences in prejudice between these groups remained largely absent we showed that as a consequence rising shares of nonmembers and nonchurchgoers have hardly resulted in a decline of prejudice additionally all dutch individuals have become more prejudiced between 1985 and 2011 irrespective of their educational level and religious affiliation which has partly offset the supposed liberalizing influence of educational expansion and secularization this development is not limited to the netherlands research has shown similar increases in negative attitudes towards minorities immigrants and immigration in other european countries over the past decades though studies into changes in ethnic prejudice are scarce this study has several implications for research on the relationship of education and religious affiliation with ethnic prejudice our results suggest that the liberalizing influence of education on ethnic prejudice as suggested by several researchers has decreased hence the idea that liberal attitudes automatically diffuse from higher educated individuals to lower educated in part through the educational system has contemporarily become open to doubt higher educated individuals do not seem immune to ethnic threat either due to increasing shares of ethnic minorities obtaining higher levels of education or due to a heterogenization of higher education which may have changed the composition of the group higher educated individuals alternatively some researchers have argued that higher educated are less prejudiced because they are more skilled at suppressing prejudiced responses in survey research and more sophisticated in defending their group ideology although this approach is sometimes contested it provides an alternative explanation for our findings namely that a taboo to express prejudice against ethnic minorities among higher educated individuals has been slowly disappearing however it is beyond the scope of our contribution to test the mechanisms behind the differential changes in ethnic prejudice among the educational categories therefore we propose this as a direction for future research moreover we found the relationship of church membership and attendance with ethnic prejudice to be largely absent this suggests that the generally accepted idea that religious affiliation strongly influences peoples level of ethnic prejudice may need refinement this was also proposed by other researchers for example hall et al found that the positive relationship between extrinsic religiosity and racism declined over time in the united states it seems that modernization has indeed eliminated the importance of religion although there might be a small group of religiously affiliated whose identity has become increasingly threatened in the secular netherlands finally we showed that even substantial shifts in the relative shares of highly educated and secular individuals have had little impact on the general level of ethnic prejudice over time because the differences in prejudice between higher and lower educated individuals declined and the differences between the religiously affiliated and nonaffiliated were small to begin with overall these findings are perfectly in line with individualization theory which proposes that peoples attitudes have become less and less determined by individual backgrounds and social institutions such as their educational level and religious affiliation therefore it is exactly this process of individualization that provides an answer to the paradox as the importance of educational attainment and religious nonaffiliation as barriers to ethnic prejudice have diminished educational expansion and secularization have not resulted in the expected decrease in prejudice in the netherlands over time several limitations of this study should be acknowledged since data containing comparable measures of prejudice over such extended time periods are scarce we could not determine whether the upward trend in prejudice is a recent or contemporary phenomenon or had already started before 1985 in addition educational expansion and secularization took off in the 1950s therefore these processes may have actually reduced prejudice in the period before our data were collected likewise we were not able to include more recent developments in ethnic prejudice although studies have shown slight decreases in negative public opinions towards the presence of ethnic minorities immigration and ethnic diversity in the netherlands future research should indicate whether that also holds for ethnic prejudice moreover we possibly underestimated the trend towards more prejudice because we were not able to examine prejudice against other ethnic minorities than the five groups in this research recently the numbers of eastern european and muslim migrants have increased substantially in the netherlands which may have evoked stronger prejudice against these groups than against the five established minority groups included in the socon surveys for example strabac and listhaug found prejudice against muslims in europe to be more widespread than prejudice against other immigrants in the netherlands a considerable share of recently migrated poles and bulgarians in the netherlands reported perceptions of frequent discrimination of their own ethnic group and these perceptions have recently intensified lastly the question remains why ethnic prejudice has increased in the netherlands acrosstheboard along with differential changes within particular social categories it seems that all social categories have become somewhat more prejudiced over time though some at a stronger pace than others certain societal circumstances could have affected all dutch individuals similarly further increasing the general level of ethnic prejudice this supposition leads us to speculate on which societal circumstances may have reinforced the general level of prejudice the persistent inflow of both economic and political migrants along with fluctuating numbers of refugees have repeatedly incited societal debates on the influx and presence of ethnic minorities this might have increased perceptions of threat among all individuals in society moreover from the 1980s onwards several liberal dutch politicians and opinion leaders have openly voiced concerns about immigration and poor integration of ethnic minorities ethnic minorities are increasingly framed as undermining the liberal dutch values which may have gradually legitimized the expression of prejudice against ethnic minorities in society justified by an appeal to free speech ironically then the liberal values which have long been the basis of tolerance towards minorities have over time become a source of free expressions of prejudice and exclusion unfortunately we could not analyze which societal changes have contributed to the upward trend in prejudice due to the confounding of age period and cohort explanations further research should address this question to summarize a longitudinal increase in ethnic prejudice has taken place in the netherlands despite educational expansion and secularization which was the puzzling paradox we tried to solve the answer is twofold firstly the liberalizing influences of educational expansion and secularization have diminished over time higher educated dutch people have converged towards the secondary and lower educated dutch while the differences between the religiously affiliated and secular dutch were largely absent from the beginning secondly these processes have set all dutch individuals free to become more prejudiced over time because immigration of ethnic minorities into the netherlands as well as to other european countries is not likely to cease these findings suggest that the trend towards more ethnic prejudice will likely continue heightening interethnic tensions in society open access this article is distributed under the terms of the creative commons attribution 40 international license which permits unrestricted use distribution and reproduction in any medium provided you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made appendix 1 see table 5 19852011 appendix 3 counterfactual analysis simulating a fixed association in this appendix we explain counterfactual analysis in a straightforward example using two categories of education and two survey years in this example 684 of the dutch had a low or middle education and 316 had a high education in 1985 within the category of lower educated respondents the percentage holding ethnic prejudice was 516 and among the higher educated it was 225 in total 422 of the sample were prejudiced in 2011 the educational distribution of our sample had changed considerably compared to 1985 the share of lower or middle educated dutch decreased to 539 and the percentage higher educated increased to 461 in total the percentage holding ethnic prejudice increased with almost 20 from 422 in 1985 to 608 in 2011 the relative share supporting ethnic prejudice increased to 685 among the lowmiddle educated respondents and to 517 among the higher educated respondents the statistical association therefore dropped with 005 between 1985 and 2011 the observed increase in ethnic prejudice between 1985 and 2011 may be due to changes in the percentage prejudiced individuals within the categories of higher and lower educated respondents previous research has shown that higher educated individuals express less prejudice than the lower educated which is supported by the percentages in tables 6 and7 to analyze the magnitude of changes in prejudice within the two educational categories we simulated a counterfactual situation for which we used the 1985 association together with the 2011 distribution of education and the 2011 sample in table 8 the column total percentages show the sample size and the distribution of the lowmiddle educated and the highly educated in 2011 the inner cell percentages on which the association is based are from 1985 as was shown in 19852011 source socon 19852011 the paradox of rising ethnic prejudice in times of… percentages and the absolute numbers in the column totals we can calculate the new absolute numbers in the inner cells there are 195 respondents with prejudiced attitudes among the lowmiddle educated and only 73 among the higher educated finally we summed both absolute numbers and calculated the simulated percentage of prejudiced respondents which amounted to 382 701 thus if the association between education and prejudice had not changed since 1985 then the percentage prejudiced individuals in 2011 would have been 382 and not 608 this means that the shift in the percentage of higher educated and lowmiddle educated individuals with ethnic prejudice is associated with a decline in prejudice of 22 points table 6 the association between education and ethnic prejudice in the netherlands in 1985 source socon 19852011 year socon 19852011 year 1985 2011 source socon 1985 2011 eisinga et al 1992 1999 2012

we aim to clarify a puzzling paradox while shares of highly educated and nonreligious individualswho generally hold less prejudicehave increased in the netherlands levels of prejudice against ethnic minorities have yet risen over time to solve the paradox we use crosssectional data from 1985 to 2011 in counterfactual analyses in these analyses we simulate that levels of ethnic prejudice within categories of education church membership and church attendance are kept constant at the 1985 level and a new simulated trend in prejudice is estimated for the 19852011 period our findings show that changing levels of prejudice within categories of education are partly responsible for the trend we conclude that the increasing share of highly educated individuals has not resulted in a decline of prejudice in the netherlands over time because all dutch have become more prejudiced over the years and in particular the higher educated

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doucet eargle criminology criminal justice law society volume 24 issue 2 with over 60 million encounters between police officers and citizens in any given year there is ample opportunity for these interactions to turn violent and even deadly the research literature on these fatal encounters has focused heavily on the killing of citizens by law enforcement and the conducive conditions and precipitating factors contributing to such events a much smaller set of recent literature however has centered on the killing of police in the line of duty even though policing ranks in the top three for occupations with the most workplace homicides the approach of researchers attempting to understand law enforcement officer deaths has varied some studies have focused on officer characteristics and incidentlevel variables while others have focused on offender characteristics additionally macrolevel studies analyzing city or microareas within a city county state and national characteristics have been conducted researchers utilizing a macrolevel approach to ascertain why these fatal incidents occur have applied theories such as social disorganization theory routine activities theory and criminal opportunity theory studies have also investigated how policies and practices within agencies impact leo deaths examining everything from training to the use of bulletproof vests and body cameras to departmental size and partnered patrol cars researchers have generally found these measures to be beneficial in reducing leo assaults and deaths however these studies have typically been narrowly focused analyzing the impact found among a small subset of agencies though there are several ways in which officers can be feloniously killed most of these fatal encounters involve firearms according to zimring and arsiniega gunfire accounted for 90 of police killed by suspects between 2008 and 2012 while some of the research on leo deaths has included measures of firearm access these studies vary in their measurement of gun availability resulting in inconsistent findings furthermore these studies failed to isolate leo firearm deaths from other felonious killings arguably gun availability measures may have better predictive power for firearm deaths specifically than for overall leo deaths line of duty deaths remain an area of concern for researchers especially as recent calls for attention to officerinvolved shootings social justice movements and antipolice rhetoric have undoubtedly made policecitizen encounters more tense for all parties involved understanding the macrolevel factors associated with leo deaths may provide insight for agency responses to policecitizen interactions as such the current study contributes to the scholarly literature by examining leo deaths for a more recent time period utilizing countylevel data to provide a nationwide examination of these deaths employing a more comprehensive measure of firearm access including a measure aimed at capturing the presence of illegal guns in a county and considering the impact of minimum training hours required of officers utilizing data from the officer down memorial page the 2015 american community surveys fiveyear estimates and other secondary sources a countylevel study of factors thought to explain leo firearm deaths between 2011 and 2019 is conducted structural variables drawn from social disorganization theory along with measures of law enforcement presence law enforcement training and gun availability are analyzed literature review several criminological theories exist to explain crime and criminality many of which have been used in studies of felonious police deaths due to its prominence in macrolevel research the current study draws primarily from social disorganization theory as such the impact of its structural components on police firearm deaths is thoroughly explored below however as evident from prior research in this area social disorganization theory alone cannot fully explain these deaths to provide a more complete analysis of this phenomenon additional covariates thought to influence leo firearm deaths along with their theoretical supports are also presented social disorganization theory developed by shaw and mckay social disorganization theory centers on how structural community disruption negatively affects the communitys ability to control residents behavior and to come together for the greater good in their seminal criminology criminal justice law society volume 24 issue 2 work shaw and mckay examined why chicago crime rates remained high even when populations changed their original model focused on three structural components of place low socioeconomic status heterogeneity and population turnover in an expansion of this theoretical model sampson and groves added measures of family disruption and urbanization as relevant structural factors it is well established in the literature how each of these factors influence crime rates across various types of crime and levels of analysis with research typically indicating a positive relationship between these structural components and crime rates for a complete review of the literature on the history and development of social disorganization theory see bellair and kubrin given these communities tend to have higher rates of crime it is expected that these areas will have an increased likelihood for policecitizen encounters with offenders that may turn deadly having turned to crime as a solution to their circumstance criminals may be more likely to fight back against police to escape and avoid punishment it is important to note however that interactions with police are not limited to criminal encounters citizens may respond negatively to police if they feel their autonomy or personal safety is threatened or if they question the legitimacy of the police additionally they may attack police if violence has occurred prior to the polices arrival to defend others against the police or if they feel contempt for police police legitimacy has been found to be lower in more disorganized communities than in less deteriorated areas as such encounters in these places may result in more police fatalities research on whether these structural components can explain felonious leo homicides has been mixed the most convincing evidence is the ability of low socioeconomic status and family disruption to explain police homicide victimization in his study testing the effects of structural covariates on officers killed between 1990 and 2000 kaminski found economic disadvantage to be positive and significantly related to these incidents these results are echoed by fridel et al adding education and two measures of family disruption to their disadvantage factor fridel et al found that police were more likely to be killed in areas with high levels of concentrated disadvantage these findings indicate that it is essential to include these components in studies of police homicide victimization ethnic heterogeneity urbanization and population turnover have received less attention and support in the literature on leo deaths overall in the limited studies capturing ethnic heterogeneity few have found a significant relationship chamlins statelevel study indicated police killings by civilians was higher where there was a larger spanish population more commonly studies include racial composition as either an independent or control variable this measure is generally related to increased police murders operationalizing heterogeneity as a single measure of racial composition however does not sufficiently capture this concept as such further research including a more complete measure of ethnic heterogeneity is warranted similarly the operationalization of urbanization has varied in the literature with researchers including measures of population size density andor percent urban contrary to the expectations of social disorganization theory much of this research has found an insignificant relationship between these measures and felonious leo deaths many of these studies focused on cities which in essence partially controls for the effects of urbanization in a countylevel analysis kaminski found measures of urbanization significantly decrease the murder of leos additional research therefore is needed to determine if this finding was an anomaly or can be replicated across diverse places lastly measures of population turnover are least likely to be included in this line of research the few studies that exist utilized measures that capture the inverse such as the population living in the same house as five years prior and owneroccupied housing units as with urbanization the findings of these studies contradict expectations of social disorganization theory while kaminskis studies failed to find a significant criminology criminal justice law society volume 24 issue 2 relationship fridel and colleagues found that officers were at a significantly higher risk of being killed where there was more residential stability the lack of consistent inclusion of this factor in leo research warrants further exploration of this measures effect on leo deaths though not the focus of the current study it is important to note that many of these results are mimicked in research analyzing nonlethal assaults against law enforcement within and across cities specifically kaminski and colleagues found that factors measuring disadvantage and transitional areas were associated with an increase in assaults against law enforcement across block groups willits agencylevel study echoes these findings indicating that the leo assault rate was higher where there was more disadvantage similarly gibbs and colleagues found concentrated disadvantage was significantly related to violence against baltimore police however like much of the leo homicide research other measures of social disorganization failed to predict these acts of violence taken together these studies give credence to the ability of some components of social disorganization theory to explain felonious leo deaths the findings regarding low socioeconomic status and family disruption are most consistent given their significant impacts on homicide these variables cannot be ignored in any macrolevel criminological examination regardless of the theoretical underpinnings of the study what has not been as thoroughly explored regarding felonious police killings however is how these variables work in conjunction with the other structural components of social disorganization theory to impact these deaths few prior studies in this area have examined all five theoretical components together in one model thus the current study fills this gap in the literature by testing the effect of all structural variables outlined in social disorganization theory on police firearm deaths utilizing recent countylevel data a more complete picture of these relationships under current social conditions is provided law enforcement factors officer training and presence encounters between police officers and citizens can be stressful for all parties involved many have argued that police training could be the key to how these situations are handled thus impacting the outcome of these interactions training requirements can vary drastically from state to state both in terms of length of training and content in the united states states average approximately 21 weeks of required training before one can become a police officer this training often consists of six major subject areas operations weapons legal education selfimprovement community policing and special topics of particular concern to researchers examining fatal policecitizen interactions is the weapons subject area specifically much of the research regarding the effect of training on policecitizen encounters has revolved around police use of force resulting in the death of a suspect rather than the police officer thus far researchers have not established a link between officer training and leo deaths these studies however are relatively outdated analyzing police deaths that occurred nearly two decades ago as coverage of fatal policecitizen interactions and calls for reform have increased it is possible that states have made significant and important changes to their training requirements in more recent years to address the publics concerns analyzing the impact of training on leo firearm deaths in the current study will provide updated information on this potential relationship relatedly police presence may also influence the rate of officer deaths in a community there are two competing hypotheses regarding this relationship from an opportunity standpoint more officers in the community would increase the potential for policecitizen encounters more interactions mean more potential for a deadly outcome this is particularly true in criminogenic areas where agencies tend to have higher rates of police officers per capita support for this hypothesis is provided by willits who found that police density was positively associated with assaults against officers on the other hand the capable guardian aspect of routine activities theory would suggest that having more officers decreases their risk of injury or death officers serve as capable guardians similarly the rational choice perspective ascertains criminology criminal justice law society volume 24 issue 2 that offenders commit crime after a costbenefit analysis a larger police presence could have a deterrent effect making potential offenders reconsider their actions if they believe the risk of getting caught outweighs the benefits of committing the crime research supporting this notion has found that locations with a greater police presence experience less crime additionally in communities with more officers per capita agencies can incorporate policies that require officers to respond to calls with a partner and would provide an increased ability to provide backup to highrisk situations having multiple officers on scene may reduce the risk of an encounter escalating as there is both an increase in capable guardians and a decrease in the offenders odds of successfully getting away results from fridell and pate support this argument finding that officer assaults were higher among singleofficer patrol cars than partnered cars testing the impact of departmental size specifically fridel and colleagues found officers from smaller departments are more likely to be killed than to use deadly force against citizens these findings lend credence to the protective effect that having more officers provides for fellow police based on prior literature incorporating a measure of leo presence is important to ascertain its impact on countylevel leo firearm fatalities gun availability much research and debate has surrounded how the availability of guns in the united states influences the nations crime rates literature in the area has been mixed with some researchers finding an increase in crime and violence related to gun availability while others find either a reduction in crime or no influence the zimringcook hypothesis states the presence of guns will result in more interpersonal conflicts turning deadly simply because of the injuries caused by such a weapon others have argued that the presence of a gun will make potential offenders react more violently in their study of intent and violent escalation phillips and maume found that the presence of a gun increases the odds of an interaction turning violent regardless of the original intent of the offender those on the opposite side of the issue contend that gunwielding victims may deter wouldbe criminals who are typically looking for an easy target who will not put up a fight from a rational choice perspective some potential criminals may forego violent acts if they believe that facing an armed victim would cause the costs to outweigh the benefits policecitizen encounters provide a unique situation for testing the effect of gun access on homicide because officers are always armed in these interactions the possibility of facing an armed offender adds an increased level of risk for officers like gun research in general research analyzing the impact of gun access on firearm fatalities of police officers has been mixed with some finding an increased risk of death where gun ownership is higher while others report no significant association these studies encounter the same issues that plague gun homicide research namely how to measure this variable as there is no national database of gun ownership most studies therefore use indirect measures such as gun magazine subscriptions firearm crime or suicide rates or gun permits to name a few gun crimes and gun suicides are common proxies in studies of police deaths utilizing a direct measure of ownership from the behavioral risk factor surveillance system along with the percent of suicides committed with a firearm swedler and colleagues found an increase in police fatalities where gun access was higher these results are supported by the work of fridel and colleagues which found an increase in these fatalities was related to higher rates of gun ownership kaminski and marvell however found no relationship between firearm use and police homicide the varied nature of these studies particularly in relation to the operationalization of gun ownership highlights the importance of continued research in this area employing a onedimensional measure of gun ownership or accessibility underestimates the presence of guns in the united states as such the current study adds to the literature by utilizing a comprehensive and multidimensional approach to more adequately assess how gun availability impacts police firearm fatalities summary of expectations research on the predictors of line of duty deaths among leos has shown that there is still a need for a more complete understanding of the factors impacting these unique homicides while there are some consistencies the review above has revealed much of the literature is mixed regarding the influence of several variables on leo deaths based on findings from the leo literature as well as research on crime rates in general each of the five structural components of social disorganization theory is expected to be positively related to leos murdered with a gun in the line of duty specifically where there is a higher concentration of indicators of low socioeconomic status greater ethnic diversity increased population turnover increased family disruption and increased density there will be more leo firearm deaths additionally an increase in officer training as well as in officer presence within the community are expected to decrease leo firearm deaths finally it is predicted that higher levels of gun availability will result in an increase in leo firearm deaths these expectations are tested in the following section utilizing countylevel data from the united states data and measures multiple data sources were utilized to compile the dataset for the current study the officer down memorial page provides information on leos who have died regardless of the cause of death for each officer the site provides a picture of the officer along with information on the details surrounding the death the site also provides the officers age agency tenure within the agency and details about their personal life the explanatory and control variables were obtained from the 2015 american community surveys fiveyear estimates the 2010 decennial census the fbis uniform crime reports individual state websites the bureau of alcohol tobacco firearms and explosives and the rand corporation unit of analysis the current study analyzes countylevel data complete data were available for 3118 of the 3142 us counties or county equivalents while conducting countylevel analyses allow for more broad generalizations across space using a spatially large aggregate may raise concerns about withinunit heterogeneity there can be variation within counties in terms of both structural conditions and law enforcement presence with the potential for countylevel characteristics to be skewed by large pockets of urban areas prior research has found however that structural covariates of homicide are invariant across space indicating that the chosen unit of analysis should not significantly impact the results while cities have been a common focus for studies of leo deaths only analyzing these places creates an urban bias in this line of research there are several agencies whose jurisdiction extends beyond city limits such as sheriffs offices highway patrol state troopers and tribal authorities analyzing only cities therefore would exclude these leo deaths this particularly affects officers in rural places as many rural counties rely solely on countylevel agencies for crime control in the current sample 443 of all leo firearm deaths were of officers employed by agencies other than local city police departments furthermore it is not feasible to utilize smaller units for a nationwide study as this would produce too many zero values thus using smaller units of analysis typically requires limiting the sample to larger places this again imparts an urban bias and does not allow for a true nationwide study to address these issues a countylevel analysis was deemed most appropriate for the current study dependent variable the dependent variable analyzed in this study is the number of duly sworn leos feloniously shot and killed in the line of duty for each county in the united states from 2011 to 2019 these years covered the most recent data at the start of the project additionally there were several highprofile cases of police being murdered during this time though most interactions with police are not deadly these incidents reflect the most serious form of violence that may be experienced by leos additionally homicide data are considered a reliable indicator of violence these crimes are more likely to be accurately reported and unlike other violent or property crimes there is less discretion in classifying homicides the odmp was utilized to obtain counts of leo deaths by county cases were limited to officers killed by gunfire those who were shot and died immediately or within one year of suffering their injuries were included in the analysis officers who died from complications with wounds inflicted years earlier were excluded this distinction is important to ensure the dependent variable is explained by the currently measured independent variables the structural characteristics that may or may not have predicted an officer being shot years ago may not be the same as those used to explain more recent police murders additionally officers from puerto rico or other territories were excluded from the analysis based on the officers agency of employment the leos death was coded to the appropriate county for state police or other officers with vast jurisdictions the event criminology criminal justice law society volume 24 issue 2 was coded in the county in which the incident occurred the counts of leo deaths coded from the odmp were then compared to the annual counts provided by the fbi in their law enforcement officers killed and assaulted reports a comparison of these sources showed data compiled from the odmp are relatively consistent with the fbi reports the leoka data include any officer feloniously killed those who died years later from complications and officer deaths in territories these cases account for most of the discrepancy between the leoka data and the data used in this study any leoka cases fitting the criteria used for case selection from the odmp were coded into the dataset and included in the final analyses this comparison also revealed 47 cases of leos shot and killed in the line of duty that were reported by the odmp but were not included in the fbis leoka data the odmp includes line of duty deaths of any leo and does not employ the criteria outlined in the leoka data when reporting these deaths to count as a leoka death the officer must have been a duly sworn member of a law enforcement agency had full arrest powers have worn a badge and have carried a firearm additionally their death must have resulted from injuries sustained while acting in an official capacity in a reexamination of those specific odmp cases the reason for exclusion from the leoka data could not be ascertained therefore these cases were retained for inclusion in the final analyses upon completion of case comparisons leo gunfire deaths were summed across the study years for each county providing the data for the dependent variable explanatory variables to test the structural components of social disorganization theory several variables were included in the analyses poverty unemployment and high school dropouts serve as measures of low socioeconomic status poverty is the percent of the county population whose income in the past 12 months fell below the poverty line unemployment is the percent of the countys civilian labor force aged 16 years or older that is currently unemployed finally high school dropouts is the percent of the county population aged 18 years and older who have not earned a high school diploma or ged the presence of foreignborn and hispanic populations captures the ethnic heterogeneity component of social disorganization theory foreignborn is the percent of the county population who were born in other countries to nonus citizens while hispanic is the percent of the county population that is hispanic or latino population turnover the third component of social disorganization theory is measured as the percent of the county population that was not living in the same house as the prior year femaleheaded households measured as the percent of county households with children under 18 years of age that are headed by a female serves as the measure of family disruption the acss 2015 fiveyear estimates provided the relative percentages for each of the above variables finally density is measured as the number of people per square mile in a county this variable was calculated by dividing the population counts from the acs 2015 fiveyear estimates by the county land area the 2010 census was utilized to obtain information on land area as this was the most recently available data that align with the 2015 population measure law enforcement factors are accounted for in the current study through two variables law enforcement presence and training to measure law enforcement presence the number of sworn leos reported to the fbis uniform crime reporting program by city county state university tribal or other agencies between 2011 and 2018 was obtained and aggregated to the county level city university and tribal agencies were coded to the appropriate county based on location 1 counts from state agencies were apportioned to counties based on population size due to the voluntary nature of reporting to the ucr program and inconsistent reporting among some agencies the leo rate was calculated as the average number of sworn officers reported from 2011 to 2018 for every 1000 people in the county counties that did not have reported counts of leos from any level agency during that timeframe were removed from the analysis this resulted in the removal of 18 counties the affected counties all had fewer than 26000 residents with 12 counties comprised of fewer than 10000 residents only one of these counties experienced the loss of an leo during the study period to determine the effect of training on leo firearm deaths the number of hours required in the police academy for each state was obtained from individual state websites this measure was converted to the number of 8hour days of required training and included in the analysis doing so aligned this variable with the measurement of other variables making the coefficient more interpretable without impacting the level of significance or the size of the variables effect in the regression models it is important to note that these hours only reflect a base level of training many agencies have additional specific training requirements before joining the force as well as continuing education training that must take place each year because counties may contain multiple agencies with varied requirements having a countylevel measure was not feasible for the current study utilizing state training hours resulted in the removal of all five counties in hawaii as statelevel requirements could not be ascertained due to the focus on officers killed with a gun it is important to include measures of gun access in the current study gun data at the countylevel is extremely rare especially when analyzing the entire nation as a result proxies for gun availability are measured at the state level an estimate of the household firearm ownership rate was obtained from the rand corporation this estimate represents the percentage of adults in the state who live in a household with a firearm to calculate this measure the rand corporation combined data from 51 nationally representative surveys that specifically ask about firearm ownership with commonly used proxies of gun access in the state such as permit to purchase laws hunting licenses background checks firearm suicides crimes committed with firearms and subscriptions to gun magazines yearly estimates of the household firearm rate from 2011 to 2016 were averaged and included in the analyses use of this variable resulted in the removal of washington dc from the analyses due to a lack of information for this variable a second gun measure is the average number of firearms recovered and traced per day in each state between 2011 and 2019 raw data on the number of firearms recovered and traced annually were obtained from the atf then converted to a daily average count each year the atf reports the number of firearms for which law enforcement agencies in each state requested a trace these traces are only for criminal investigations in which the use of a firearm was confirmed or suspected tracing firearms allows law enforcement to link offenders to a gun used in a crime it also assists with detecting traffickers of illegal guns and recognizing trends in the movement of those firearms it is important to note that not all recovered guns are traced though the atf encourages agencies to do so furthermore it is recognized that not all guns used in crimes are illegally obtained however research has found the vast majority of prison inmates did not purchase guns used in the commission of their crimes from a licensed dealer nearly half obtained the weapon from the underground market or stole it control variables there are known correlates of crime that must be included in any model predicting violence the first variable is the percent of the county population that is african american though african americans make up about 13 of the us population they account for more than 27 of arrests each year as a result crime studies consistently control for the size of this population additionally criminological literature indicates that young people are more likely to be both victims and offenders of crime to account for this the percent of the county population that is 15 to 24 years old is controlled a third control variable is location the south has a known history of violence and has the highest murder rate in the united states research on the southern subculture of violence has shown that southern violence can be felt across the country as southerners have moved elsewhere taking their culture with them additionally research on leo deaths has indicated that a regional effect may exist as a result the percent of the county population that was born in the south is controlled 2 data for these variables were obtained from the 2015 acs fiveyear estimates descriptive statistics and data reduction to discuss the characteristics of officers shot and killed in the line of duty several additional pieces of information were coded from the odmp including demographic characteristics of the officer and the officers tenure within the agency while the officers age was specifically provided the officers sex and race were ascertained from the photograph provided on the website it is recognized that this is not the most ideal way to determine the officers race those whose race was not easily identifiable were coded as unknown these demographic characteristics are only used for descriptive purposes and are not included in the analyses the description of events was then read and used to code variables related to the circumstances under which the death occurred these variables included the reason the officer was on the scene the number of offenders present the type of gun used by the offender and if the officer was alone during the incident of the 393 officers murdered by gunfire from 2011 to 2019 95 were male and approximately 85 were white on average these officers were 39 years old and had served 12 years on the police force nearly criminology criminal justice law society volume 24 issue 2 38 were responding to a call for service and more than 34 were alone at the time of the incident of the 235 cases where the type of gun was specified 677 were murdered with a handgun including 17 incidents in which the officers own gun was used against them these 393 officer deaths indicate approximately 44 officers are shot and killed each year over the nineyear timeframe leo firearm deaths fluctuated between a low of 28 and a high of 62 a closer examination of the counties in the current dataset shows that large urban counties experienced the most leo firearm deaths maricopa county had seven officers killed while los angeles county and dallas county each had six leo firearm deaths however these counties tend to have more officers and thus lower rates of these deaths the highest leo firearm death rates are found in rural counties clay county experienced the highest average death rate with 247 officers killed for every 1000 sworn officers dillingham census area and broadwater county followed this with each experiencing an average of approximately 11 leo firearm deaths for every 1000 sworn officers in the county table 1 provides descriptive statistics for the dependent explanatory and control variables from the 3118 counties analyzed in the current study on average counties had fewer than one officer killed in the line of duty over the nineyear timeframe this statistic is not surprising given the rare nature of these events when analyzing the rate of death per year on average approximately 10 officers were killed each year for every 100000 officers in a county the measures of socioeconomic status show that on average 167 of the county population lives in poverty 78 of the countys civilian labor force is unemployed and 149 of the county population does not have a high school diploma most counties do not experience high levels of ethnic heterogeneity on average less than 5 of the countys population is foreignborn and approximately 9 is hispanic most county populations are relatively stable with only 136 of the population moving in the prior year on average additionally on average 77 of households with children in the county are headed by females the density measure shows that there are approximately 264 people per square mile in a county measures directly related to law enforcement show that on average there are only two officers for every 1000 people in a county and that states require an average of approximately 74 8hour days of training for their officers the household firearm ownership rate indicates that on average nearly 41 of adults live in a household with a firearm finally law enforcement agencies recovered and traced approximately 22 firearms each day on average though there were condition indices greater than 15 none produced variance proportions greater than 050 on more than one variable based on the significant relationships shown in the correlation matrix an obliquely rotated principal components factor analysis was performed on conceptually similar variables each factor includes variables with loading scores greater than 050 and eigenvalues greater than 1 the first factor resource disadvantage consists of the variables for poverty femaleheaded households unemployment high school dropouts and black femaleheaded households and black though not direct measures of socioeconomic status commonly load with measures of economic or resource disadvantage because these households are more likely to be impoverished than other household types additionally table 2 indicates that all variables in this factor are significantly related with either a moderate or a strong association ethnic heterogeneity is the second factor composed of measures of the foreignborn and hispanic populations in the county 3 according to table 2 these variables have a strong and significant relationship finally the unstable population factor consists of the residential instability and age structure variables table 2 shows that these variables have a moderate and significant relationship this association may be explained by the fact that young adulthood tends to be the most mobile time of life for individuals furthermore these variables have been found to load together in prior analyses diagnostic analyses for multicollinearity conducted after the creation of these factors indicated improvement in these statistics vifs were reduced to less than 25 and all condition indices were below 30 criminology criminal justice law society volume 24 issue 2 analytic methods negative binomial regression techniques were utilized in the current study to estimate predictors of leos being shot and killed in the line of duty these deaths are statistically rare with most counties not experiencing an leo firearm death in any given year this can result in skewed distributions and potentially nonlinear relationships statistical methods that do not rely on the assumption of linearity must be employed as results from normal regression techniques are at risk of being highly distorted negative binomial regression is one of these statistical methods to analyze data using this technique the dependent variable must be measured as a count outcome indicating the number of occurrences of a particular phenomenon a likelihoodratio test for overdispersion revealed that negative binomial regression was appropriate for use with these data cluster estimation was used to produce robust standard errors clustered by state doing so adjusts for heterogeneity and within state correlated errors additionally this command essentially treats the model as a multilevel model taking into consideration variables that are measured at the state level finally models were offset by the log of the population at risk to adjust for the likelihood of these murders taking place and to allow the coefficients to be interpreted as a change in the rate rather than counts because county boundaries simply serve as identifiers of geographical space crime that occurs in one county may be influenced by crime occurring elsewhere as a result the potential for spatial dependence must be recognized morans i is a standard statistic used for assessing this issue when this value exceeds 020 there is evidence of significant spatial autocorrelation among geographic units to test for this both a firstorder rook and queen contiguity weight matrix were created in geoda neither weight matrix produced a morans i value greater than 008 indicating spatial autocorrelation is not a concern in the models results table 4 presents the results for models predicting leos shot and killed in the line of duty variables are presented in a stepwise approach to ascertain if there are any mediating relationships model 1 predicts leo firearm deaths using standard social disorganization variables this model indicates that resource disadvantage and ethnic heterogeneity are significantly related to leos killed by gunfire however the ethnic heterogeneity measure is opposite the predicted direction to determine the strength of the coefficients the incidencerate ratios are presented incidencerate ratios are calculated as the exponential of the unstandardized coefficients and represent a percent change in the dependent variable for each unit increase in the independent variable holding all other variables constant based on this calculation each unit increase in resource disadvantage results in an approximately 424 increase in the rate of leo deaths by gunfire additionally there is a 121 decrease in the rate of leo firearm deaths for each unit increase in ethnic heterogeneity model 2 utilizes measures specific to law enforcement in predicting leo deaths by gunfire each of these variables is negative and significantly related to these homicides there is a 152 decrease in the leo firearm death rate for each unit increase in the rate of leos in a county furthermore every unit increase in the number of 8hour training days required by the state results in an approximately 08 decrease in the leo firearm death rate model 3 includes the two measures of gun availability to predict leo firearm deaths both variables are positive and significantly related to these homicides specifically a one unit increase in the household firearm ownership rate results in a 32 increase in the rate of leos killed by firearms additionally each unit increase in the average number of guns recovered and traced each day results in a 08 increase in the leo firearm death rate the full model includes the social disorganization law enforcement and gun measures along with the control variables in this model all measures of social disorganization are significant resource disadvantage and ethnic heterogeneity retained their significance from model 1 while the unstable population and density measures reached statistical significance in this model the effects of both resource disadvantage and ethnic heterogeneity slightly increased each unit increase in resource disadvantage results in a 455 increase in the leo firearm death rate ethnic heterogeneity decreases the rate of leos killed by gunfire 154 for each unit increase in this measure additionally there is an 81 increase in the rate of leos killed by gunfire for each unit increase in the unstable population regarding density the incidencerate ratio is unable to accurately show the effect of this measure on the leo firearm death rate as it appears to have a value of 1 to provide a meaningful interpretation a standardized percent change was calculated instead to do so the unstandardized coefficient for density was multiplied by its standard deviation and then the exponent of this product was taken this value is converted to a percent by subtracting one and multiplying by 100 this calculation indicates that each standard deviation increase in density results in a 68 increase in the rate of leos killed by gunfire three of the four remaining independent variables of interest maintain their significance in the final model leo presence has a larger effect than seen in model 2 indicating a 234 decrease in the leo firearm death rate for each unit increase in the leo rate though maintaining significance the household firearm rate has a reduced effect on the rate of leos killed with a firearm indicating that a one unit increase in this measure results in a 23 increase in the leo firearm death rate lastly the recovered and traced firearms measure appears to have an identical effect as in model 3 however this is primarily the result of rounding a closer examination of the irr shows a slightly reduced effect in the final model with a 075 increase in the leo firearm death rate for each unit increase in this measure to aid in interpreting the results presented above the predicted counts of leo firearm deaths were plotted under varied county characteristics because resource disadvantage has the largest effect on these deaths it serves as the base model for the plots predicted leo firearm death counts were obtained as resource disadvantage varies from three standard deviations below to three standard deviations above the mean as shown in figure 1 when moving from less to more disadvantaged counties the predicted number of leo firearm deaths increases from 005 to 046 while these numbers are small it is important to remember these deaths are rare with an average of 0125 leo firearm deaths over the nineyear timeframe thus highly disadvantaged counties experience nearly four times the average count of these deaths from this base model the rate of leos in a county was varied by setting it to its minimum value as well as to three standard deviations above its mean the minimum value was chosen because counties cannot have negative leo rates nor can they experience an leo firearm death if there are no leos as displayed in figure 1 having a lower leo rate in a county increases leo firearm deaths regardless of the level of resource disadvantage however this impact is greater in more disadvantaged counties conversely increasing the leo rate reduces the expected counts across all levels of resource disadvantage with the greatest reduction evident in highly disadvantaged counties these results show that the impact of the rate of leos on leo firearm deaths increases as counties experience more resource disadvantage the final manipulation examines how leo firearm deaths in low to high resource disadvantage counties are affected by having firearms in the household of the gun measures this variable had a stronger effect on leo firearm deaths the household firearm rate was set to three standard deviations below and above the mean figure 1 indicates that having lower household firearm rates reduces the expected leo firearm death count across all levels of resource disadvantage the negative impact on leo firearm deaths is more evident when examining the household firearm rate at three standard deviations above the mean having a greater percentage of households with access to firearms increases these counts across all levels of resource disadvantage furthermore these predicted counts show that having more firearms is more detrimental than having fewer officers regardless of the level of disadvantage in a county additional tests and diagnostics several additional steps were taken to ensure model fit and accuracy as mentioned above negative binomial regression is utilized when there is evidence of overdispersion however misspecification of the poisson model could result in overdispersion tests for interaction effects and outliers were conducted to ensure these were not causes for misspecification no interaction effects were identified in the models based on diagonals from the hat matrix los angeles county new york county and philadelphia county were identified as potentially highleverage counties however removal of these counties from the analyses did not produce substantively different results in the final model additionally the likelihoodratio test for overdispersion remained significant even after these counties were removed model misspecification can also occur when relevant variables are excluded from the analyses failing to account for potentially important predictors could introduce bias into the model because of the potential relationship between the overall occurrence of crime on leo firearm deaths both the violent and property crime rates were included as control variables neither of these variables however produced significant effects on leo firearm deaths in the full model discussion conclusions and implications with millions of policecitizen interactions each year understanding the conditions in which these encounters turn fatal is crucial for protecting all parties involved though one of the most dangerous occupations the literature on officers being murdered in the line of duty is lacking in both the number of studies conducted as well as the consistency of their findings the current study aimed to contribute to the literature by examining the influence of social disorganization law enforcement presence law enforcement training and gun availability measures on leo firearm deaths in us counties the results show that multiple components of social disorganization theory have the same impact on leo firearm deaths as they do on crime in general resource disadvantage the unstable population factor and density significantly predict an increase in the leo firearm death rate the findings regarding resource disadvantage are not unexpected as prior research has consistently found that these measures significantly increase leo deaths furthermore resource disadvantage has been linked to higher crime rates overall which may result in increased contact between law enforcement and potential offenders that could turn deadly research has also shown that higher levels of disadvantage tend to coincide with a distrust of law enforcement and reduced levels of police legitimacy while law enforcement agencies cannot change the structural conditions of the neighborhoods they patrol they can adjust their approach based on these conditions agencies working in disadvantaged communities should focus on rebuilding relationships with citizens by promoting community engagement so that officers are seen as communitybuilders rather than just law enforcers furthermore involving residents in how community crime issues are handled would foster greater trust in the police as well as social cohesion among members once trust is established officers could serve as a resource that connects community members with necessary services to resolve the issues that led to the need for police involvement in the first place these actions may work to reduce not only leo deaths but also overall rates of crime and violence while the resource disadvantage component performed as hypothesized and expected based on prior research the remaining measures of social disorganization are either contradictory to the literature or the study hypotheses the unstable population factor is positive and significantly related to leo firearm deaths as hypothesized though these findings contradict prior research other works utilizing this measure either failed to find significance andor the variable operated in a direction opposite what was predicted one explanation for the current finding is the inclusion of the age structure variable as a measure of instability while not traditionally included in an instability factor prior research has found a marginally significant effect of transitional areas on police assaults because young people are in a more transitional phase of life than older adults incorporating age structure into an instability factor provides a more complete measure of this concept another contradictory finding is the significant decrease in leo firearm deaths related to increased ethnic heterogeneity prior research has provided mixed results that either indicate a positive criminology criminal justice law society volume 24 issue 2 association or fail to find a significant effect these studies primarily measured racial heterogeneity through use of either a diversity index or a single measure for percent black utilizing a measure that captures the foreignborn population may account for this discrepancy it is important to note that focusing on this group falls in line with the original intention of shaw and mckay in their specification of heterogeneity though this group has been expected to coincide with increased crime research has shown declines in crime in areas with larger foreignborn or immigrant populations furthermore the recency of migration plays a role in criminality sampson and colleagues found that thirdgeneration americans were more likely to engage in violence than firstgeneration immigrants with approximately 52 of the current immigrant population in the united states having entered the country after the year 2000 it stands to reason that counties included in these analyses are primarily comprised of the less crime prone firstand secondgeneration immigrants the final social disorganization measure density is found to positively impact leo firearm deaths as hypothesized prior literature analyzing measures of urbanization however is contradictory to this finding few studies on leo deaths or assaults indicate either a negative or insignificant relationship while others fail to account for this potential effect altogether choosing to use density as the measure of urbanization may partially account for these findings as many studies utilize percent urban to operationalize this concept while both can capture urbanization a density measure touts a few advantages density accounts for individuals living within a boundary that is uniform and unlikely to change over time this provides a consistency to the measure and its definition the us census bureaus measure of urban areas on the other hand is based on how things look from the air urbanized areas or urban clusters are based on where the population tends to accumulate which grows over time in fact the percent of the us population that lives in an urban area has increased dramatically since the 1950s though most of the land mass of the united states remains rural density is able to capture the fact that there are more people living on the same area of land furthermore a portion of the rural population lives within a metro area though distinct from urban it can be argued that these populations are different from the truly rural population that does not have as easy access to urban amenities law enforcement presence is one of the most significant measures predicting the leo firearm death rate each additional officer for every 1000 individuals in a county decreases the rate of these deaths by approximately 23 this finding lends support for the deterrent andor protective effect of officers whether by reducing crime in general or deterring criminals from responding violently in encounters with multiple officers on the scene additionally it gives merit to increasing the leo rate in a county having more officers per capita would give departments the ability to instate twoofficer patrols when deemed necessary which may reduce the risk of assault against officers furthermore it may allow for faster response times to calls for backup providing assistance in potentially deadly situations unfortunately budget constraints and recent movements to defund the police have made it difficult for departments to recruit new and retain experienced officers training on the other hand is not statistically significant in the final model which supports prior research unlike the work of fridell and colleagues these results indicate a negative relationship between training and leo firearm deaths the measurement of this variable could play a role in this finding finally both gun availability measures are significantly related to increases in leo firearm deaths specifically where there is a higher rate of household firearm access and more guns recovered and traced each day there are more leos shot and killed in the line of duty prior research had comparable results indicating a positive relationship between gun access and leo fatalities these findings imply that officers in communities with greater access to guns should be aware of the increased risk of interactions turning fatal thus one may deduce that reducing gun availability would provide further protection for officers additional analyses show that when a states household firearm rate is one standard deviation below the average there is an approximately 206 reduction in the leo firearm death rate these results appear to support research indicating that the presence of guns increases the likelihood of interactions turning violent one way to address the gun availability issue is through legislation however caution must be taken when deciding which gun laws are implemented as they can have differing impacts on gun homicides research has found that right to carryshall issue laws increased homicides while banning those with violent misdemeanors from having guns reduced these crimes an examination of other laws has found either mixed or insignificant impacts on homicide the effects of these laws on felonious police deaths specifically have not been as widely evaluated limited research however has found a reduction in these deaths in states with concealed carry laws limitations and directions for future research there are several data limitations in the current study that may help guide the direction of future research one such limitation is the measurement of training which only reflects the overall minimum statemandated training hours required to join the police force the focus on overall training may contribute to the lack of significance of this measure it is possible that the content of the training plays an important role in preventing these deaths furthermore most agencies require additional training beyond the state minimums including yearly training hours revisiting what was learned in afterhire or required yearly training could prove beneficial as officers may be out of practice with some of the techniques learned at the beginning of their careers research by andersen and gustafsberg highlights the importance of additional specific training their study found that officers who received supplementary training as part of a training intervention group were more likely to make correct use of force decisions than officers in the control group unfortunately because this is a countylevel analysis obtaining agencyspecific information on the amount and type of training was not feasible for the current study future research should examine the effect of training in specific content areas to determine what impact if any that may have on officer fatalities furthermore as highlighted above the recent calls for police reform warrant researchers to continue to monitor the effect of training to ascertain if any changes made have significant impacts on future leo deaths another data limitation surrounds the flaws in the gun availability measures even though the findings of the current study are as expected based on prior research the rand corporations household firearm rate conflates actual gun ownership with proxies for gun access some of which include the illegal use and potentially the illegal possession of firearms even the atf data though intended to measure illegal firearms does not distinguish illegally owned firearms from those legally owned but illegally used prior research has indicated the importance of separating legal from illegal firearm access doucet et al found that illegal firearm possession significantly increased the homicide rate in new orleans census tracts while legal firearm possession decreased the homicide rate future research should attempt to ascertain if there are differential impacts of legal and illegal gun possession on leo firearm deaths leo deaths will remain an issue faced by agencies into the future it is the hope that insights from this study will assist law enforcement with making policy changes that protect their officers and instill confidence among individuals considering joining the profession because the new york city police department covers five countiesboroughs these officers were also apportioned out to each of the five boroughs based on their population size 2 the southern regional effect found to be significant in kaminski was based on a dummycoded categorical variable with the northeast as the reference category the born in the south measure used in the current analysis was replaced with a dummy coded variable based on the census definition of southern states measuring the regional effect in this way also failed to attain statistical significance in the full model further analysis revealed that this measure did not improve the model fit as such born in the south was retained to represent a regional effect 3 the ethnic heterogeneity factor was replaced with blaus dissimilarity index as an alternative measure however it failed to attain statistical significance and did not improve the model fit an analysis of bic showed the model fit was better when utilizing the original measure of ethnic heterogeneity rather than blaus dissimilarity index as a result the original measures were retained for the analysis

the current study examines the macrolevel covariates influencing law enforcement officers leos shot and killed in the line of duty social disorganization theory as well as literature on police training police presence and gun availability creates the theoretical framework underpinning the current investigation leo firearm deaths between 2011 and 2019 were obtained from the officer down memorial page odmp aggregated to the county level then merged with countyand statelevel data from secondary sources negative binomial regression was utilized to examine the effect of social disorganization police training police presence and gun availability on leo firearm deaths of the social disorganization measures resource disadvantage is found to have the strongest impact on leo firearm deaths while population instability and density also significantly increase these deaths ethnic heterogeneity has a significant negative effect furthermore police presence has a protective effect against these murders while gun availability increases these deaths limitations of the study along with policy implications and suggestions for future research are discussed

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introduction raising divorce and remarriage rates mean that reconstituted households formed by a married registered or cohabiting couple and at least one noncommon child are becoming increasingly common children in reconstituted households tend to have poorer academic outcomes and experience lower wellbeing compared to children in twoparent households the redistribution of resources following separation divorce or widowhood have a social and economic impact on individuals and their households it is also likely to have an impact on resource allocation between the members of the couple the majority of research on intrahousehold inequality has focused on couples and finds that women have less access to household resources compared to men as a result household measures underestimate poverty among women as well as the extent of gender inequality research on inequality between generations has generally found households to prioritise children although with variations both between and within countries to date relatively little attention has been given to the factors that may explain such variations children and young adults in reconstituted households regardless of whether they live with one or two biological parents tend to have lower educational attainment and a higher risk of antisocial behaviours than children in intact households these poorer outcomes have been associated with the financial and emotional impact of divorce andor bereavement on children as well as the impact of repartnering on children indeed the negative effect of divorce decreases when the mother has high resources suggesting that more advantaged households may be able to protect children from the negative effects of divorce however others find family instability to also play a part in explaining the negative outcomes of divorce for example sweeney finds a positive association between the cumulative number of changes experienced during childhood and negative outcomes during childhood and early adulthood growing up in a reconstituted household is associated with an increased risk of poverty and emotional behavioural issues repartnered couples tend to follow more individualised patterns of resource sharing compared to first partnerships a recent study in the us found cohabiting and married couples with noncommon children are less likely to pool their resources compared to those with common children only reduced pooling is likely to have an impact on children access to resources particularly where only one of the members of the couple identifies as a parent to the children in the household however evidence in this respect is limited data that allows identifying individual outcomes is rare and where it exists sample size tends to be an issue using a pooled sample for 22 european this paper examines the intrahousehold allocation of resources between children and adults and between adults in reconstituted and intact couples across welfare regimes in doing so it addresses the following questions do reconstituted households show different patterns of resource allocation than intact households how does it intersect with gender and finally are there geographical variations in the observed patterns in doing so it advances research on the determinant of intrahousehold inequality and provides novel evidence on the processes of intrahousehold allocation in reconstituted households and their consequences for child poverty background research on intrahousehold inequality has chiefly focused on couples and found women to have less access to household resources compared to men even when resources are pooled additionally womens access to resources is positively associated with their economic contribution to the household in contrast the presence of children appears to increase gender inequality within the couple women have less individualistic spending patterns and are more likely to reduce their own spending when there are children in the household childrens expenses tend to be covered by mothers salaries similarly the administration of pooled resources by the mother has been associated with better childrens outcomes given that pooling is positively associated with children access to resources and reconstituted households are less likely to pool their resources children growing up in reconstructed household may have less access to resources than their peers in intact households studies on sharing between children and adults find that households tend to prioritise children needs with adults sacrificing their own needs when necessary to cover the needs of children in low middle and highincome countries although it is not a universal trait and some studies find children to be at a disadvantage comparative analyses in europe have shown country variations in the intrahousehold allocation of resources the factors that shape betweencountry differences in intrahousehold inequality are still little understood with economic cultural and social factors all likely to influence household resource allocation countries in the eusilc are diverse in terms of political and demographic characteristics deprivation also rates vary by country with eastern european countries with lower income per capita generally showing higher deprivation rates thus it can be expected that intrahousehold patterns vary geographically one of the key advantages of the european survey on income and living conditions is the potential for analysing crossnational variations to allow sufficient sample for analysis while still exploring international variability countries have been grouped into three welfare regimes an approach widely used in the family literature western european or continental southern european and eastern european the scandinavian countries as well as the netherlands the uk and ireland were excluded from the analysis due to specificities in data collection the three regimes differ both in deprivation levels and the prevalence of reconstituted couple households the poorest countries tend to have higher levels of child deprivation thus child deprivation is lowest in western europe and highest in eastern europe with the southern european countries somewhere in between although there are also important variations within regimes with countries such as slovenia and czechia with belowaverage child deprivation rates reconstituted couple households are most common in western europe compared to southern and eastern europe where coresidence with extended family is more common particularly but not only in case of economic difficulty eg following a divorce evidence on the prioritisation of children in reconstituted households has largely focused on adult children studies in the us have shown that on leaving home children of repartnered parents receive less support than those of intact families in the netherlands examined the forms of support provided to adult children and found mothers and stepfathers to provide more forms of support than fathers and stepmothers suggesting that the gender of the parent matters comparatively little is known regards to differences in expenditure or investment during childhood research on nonresident fathers finds that they tend to make smaller financial contributions than resident fathers particularly after repartnering in finland antfolk and colleagues find found more willingness to invest in biologically related children compared to nonrelated children which could result in less access to resources for nonbiological children based on this literature the following hypotheses are formulated h1 children in intact households are more likely to be prioritised than children in reconstituted couple households h2 adult women are more likely to be deprived compared to adult men with regards to crossnational variations the expectation is that h31 all three regimes will prioritise children over adults h32 reconstituted households are expected to be poorer across regimes with larger penalties in eastern and southern europe where such households are less common and overall deprivation rates higher methods research on intrahousehold inequality has tended to take one of two approaches the analysis of expenditure or the analysis of individual deprivation a key advantage of expenditure data is that it is regularly collected and widely available the main disadvantage is that it often offers limited detail on who benefits from household expenditures generally only a few items are disaggregated by age and or gender this means that conclusions about how households distribute resources rely on the information on a small subset of items another limitation is that it does not account for differences in need between household members or in the cost of items deprivation measures overcome these limitations by measuring the ability of households andor individuals to afford a range of items widely identified as necessities thus these reflects the ability to cover necessities as opposed to the cost of items and are often viewed as better measures of living standards than either income or expenditure the paper exploits the 2014 adhoc material deprivation module of the eusilc the module is unique in that it collected material deprivation data for children as well as individual adults in the household enabling the study of intrahousehold inequality the analysis is limited to heterosexual couples with children as only two samesex couples with children were identified focusing on couples allows reducing variability by excluding threeplus and single adult households which are likely to have different sharing patterns households with at least one child not common to both partners are labelled as reconstituted households parenthood is selfdefined and may include both biological and adopted children this means that some reconstituted families may not be captured by the data if the new partner had adopted or reports children as their own in the survey children are assigned to a single household meaning that it is not possible to assess the potential effect of postseparation custody arrangements approximately 80 of those who live with one parent live with their mother and 20 with their father table 1 shows key characteristics of intact and reconstituted households reconstituted households are more likely to be income poor and to experience difficulties to make ends meet than intact households they are also more likely to be households with three or more children somewhat more likely to be femaleheaded and couples are less likely to be married all three being factors associated with increased risk of poverty children and adults are considered to be deprived of an item if they do not have it because it cannot be afforded ie enforced deprivation the child index is the sum of enforced deprivation on 11 childspecific items reflecting material and social necessities the reference adult replies for all children in the household thus it is not possible to identify differences between children in the household furthermore the identification of child deprivation relies on the reference adult knowing and accurately reporting children preferences and access to resources research in the uk concludes that children and adults agree on whether children have access to items although children are more likely than adults to identify social aspects as necessities the adult index is the sum of six individual deprivation items to enable comparisons between children and adults a summary index is created where all adults are considered as deprived if any adult in the household is deprived this mirrors data collection on the child items to assess the robustness of the results two thresholds are used throughout one item thresholds are too sensitive to variations in a single item while when more severe thresholds are used deprivation levels in western europe are too low to allow for analysis to assess the intrahousehold allocation of resources between children and adults and following the deprivation literature households are classified into four categories according to whether children andor adults are deprived multinomial logistic regression is used to identify the predictors of intrahousehold allocation of resources the final section explores gender inequality within the couple through bivariate analysis and logistic regression models analyses are conducted using complex samples results child deprivation in intact and reconstituted households child deprivation rates range between 6 in western europe 15 in the south and 25 in eastern european countries children in reconstituted households are more likely to be deprived than their peers in intact households overall 18 of children in reconstituted households are deprived compared to 13 in intact households source eusilc 2014 there are however wide variations across welfare regimes differences between regimes are larger than between households within a regime however children in reconstituted households in eastern europe are particularly vulnerable 48 are deprived double the figure observed in intact households for western and southern europe the ratio is smaller at 16 and 17 respectively the use of a 3 item threshold results in lower deprivation rates but the patterns observed are unchanged and does not alter the conclusions age and intrahousehold inequality to identify intrahousehold inequality between adults and children households have been source eusilc 2014 to further assess whether there are significant variations in intrahousehold patterns of inequality between intact and reconstituted household and across regimes table 5 below reports the results of a multinomial regression model the dependent variable is intrahousehold resource allocation between children and adults in addition to welfare regime and household configuration the regression controls by known predictors of deprivation to better reflect the factors associated with intrahousehold inequality rather than deprivation itself the reference category are households where adults are deprived but children are not the model presented here corresponds to the pooled sample as the results were consistent across regimes in all three welfare regimes reconstituted households are less likely than intact households to be in the nondeprived category this is consistent with the higher risk of poverty and deprivation rates experienced in reconstituted households no significant effects are observed for child only deprivation the findings are robust to the use of a more severe 3 items threshold although some effects become nonsignificant thus there is no indication of differences in the allocation of resources between intact and reconstituted households in accordance with the descriptive results households in southern and eastern europe are overall more likely to be deprived and have a higher probability of both adults and children are deprived than those in western europe furthermore both southern and eastern regimes are associated with a higher probability of child only deprivation reconstituted households have a higher probability of both adults and children being deprived as a result children in reconstituted households are more likely to be deprived than children in intact households however the hypothesis that children in reconstituted households are less likely to be prioritised is not supported by the data the results indicate that the higher probability of deprivation experienced by this subgroup reflects lower resources rather than differences in their allocation the eusilc deprivation questions do not allow to identify differences between children eg common vs noncommon children that said given that the survey enquires whether any child in the household is deprived less prioritisation of noncommon children should translate into relatively more child only deprivation in reconstituted households from the comparison between adult and child deprivation outcomes there is no evidence that worse outcomes among children in reconstituted households are associated with reduced prioritisation of children in these households gender and intrahousehold inequality this section assesses whether living in a reconstituted household alters inequality within couples the literature review identified both women and parents as more likely to go without and experience deprivation so that children do not thus the protection of children may come at the cost of increased deprivation among mothers the results do not offer strong support for this notion generally couples tend to be fairly equal in terms of deprivation only in 6 of households there are inequalities between couple members in twothirds of these households women are deprived while men are not in the remaining cases it is men who are deprived reconstituted couples are somewhat more likely to have unequal deprivation patterns although the differences are not significant the model confirms that women at higher risk of deprivation although differences are small in terms of effect size reconstituted households at a higher risk of deprivation and women in all households are at a higher risk of deprivation but there is no significant additional risk for women in reconstituted households in separate models not shown no significant effect is observed for parenthood suggesting that gender and parenthood effects may intersect although the data does not allow to examine such hypothesis further all in all the results do not support the notion that intact and reconstituted households differ substantially in terms of intrahousehold deprivation patterns children in reconstituted households are more likely to be deprived because theirreconstituted households are more likely to be poortend to be poorer the increased risk of deprivation persists after controlling by poverty indicators however there is no evidence that reconstituted households may be less likely to prioritise children gender inequality in deprivation in couple households are small and that is also de case in reconstituted households although there is some evidence of higher risk for women the effects are not statistically significant discussion this paper has explored intrahousehold inequality in intact and reconstituted households the results are consistent with previous literature that indicates that households tend to prioritise children needs this is the case across regimes and for both intact and reconstituted households that said while the focus here has been on agespecific deprivation to uncover household allocation patterns children are also affected by the conditions of the households in which they live antipoverty policies should retain a household perspective children in reconstituted couples are more likely to be deprived compared to children living in intact households yet both the descriptive and multivariate analysis of intrahousehold allocation patterns suggest that the higher risk of child deprivation in reconstituted households is associated with lower overall resources there is no evidence that reconstituted households are less likely to prioritise children needs in fact the descriptive results suggest that reconstituted households have higher rates of adultonly deprivation compared to intact households although the difference is not statistically significant there are several possible interpretations for such findings the results may partially reflect methodological differences with regards to previous studies first adults may prioritise childrens needs with reduced investment in noncommon children manifesting later in life alternatively while noncommon children may receive overall fewer resources also during childhood such difference does not translate into child deprivation reconstituted households may be underreporting child deprivation however this seems unlikely given that reconstituted households in particular report high rates of child deprivation finally it is also possible that as reconstituted families become more common the meaning of family and kinship is redefined and stepparents may increasingly view and treat their stepchildren as their own future research should consider whether and under which circumstances investment in children varies over time similarly collecting individual child data would allow testing for differences between siblings in line with evidence on gender inequality within couples the analyses show women are at higher risk of individual deprivation although differences are small gender inequality in reconstituted households are somewhat larger than in intact households but again the effect is not statistically significant there is no evidence of an additional penalty for women in reconstituted households or of a parenthood penalty the indeed the gap between reconstituted and intact households is the largest in eastern europe where almost half of the children in reconstituted households are deprived of two or more items in the region reconstituted couples are less common partially reflecting the higher prevalence of multigenerational coresidence the gap between intact and reconstituted households is lower in western europe but the notion that the gap reduces as reconstituted households become more common is only partially confirmed the increased risk experienced by these households in eastern europe may partially reflect a selection effect where households without family support may be at higher risk of deprivation in the first place notwithstanding the biggest differences are observed between regimes rather than between intact and reconstituted households within regimes in all three regimes it is rare for children to be deprived while adults are not however some differences emerge that open new research questions adult only deprivation is most common in western europe and least in the eastern bloc eastern european countries show both the highest prevalence of deprivation and the highest prevalence of child only deprivation 5 compared to 12 in the western and southern regimes the effect persisted in the regression model after controlling for poverty status educational attainment and household configuration while this finding could be interpreted as a positive association between the overall prevalence of deprivation and child only deprivation such interpretation is at odds with research in sweden which found a stronger prioritisation of childrens needs in times of economic difficulty as well as the wider evidence on the prioritisation of children in low and middleincome contexts future research should further explore country variations in the intrahousehold allocation of resources the finding that households with different configurations strive to protect children from the consequences of poverty provides additional support for programmes like the european child guarantee which intend to provide families in poverty with additional resources appendix 1 child and adult deprivation indicators in the eu

an increasing number of children are growing up in reconstituted households formed by a couple and a noncommon child reconstituted households tend to be poorer which is associated with worse behavioural and developmental outcomes additionally there is evidence that noncommon children receive less economic support from their parents upon leaving the parental home using agespecific deprivation data collected in the 2014 european survey on income and living conditions this article compares the allocation of resources in reconstituted and intact couple households it shows that indeed children in reconstituted households are more likely to be deprived compared to those in intact households however it finds no evidence that reconstituted households are less likely to prioritise children the findings hold across welfare regimes women are more likely to go without compared with men although differences are small

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conceptual and theoretical foundations of research on social and cultural processes in the environment of the titular nation of the ukrainian ssr during the 1960s and 1970s koncepcyjne i teoretyczne podstawy badania społecznokulturowych procesów w środowisku tytularnego narodu ukraińskiej srr w latach sześćdziesiątych i siedemdziesiątych xx wieku • a b s t r a c t • the article considers the conceptual and theoretical foundations of research on social and cultural processes in the environment of the titular nation of the ukrainian ssr during the 1960s and 1970s it is characterized by the semantic content of concepts of titular nation and indigenous people in the ukrainian ssr identified primarily with ukrainians who were united by a single language faith spirituality national traditions customs culture ethnic origin and ancient residence on the territory of ukraine the official name of which was determined by their nationality the conceptual components of the research are interpretation of the following concepts of ukrainian ethnos ukrainian ethnic territory or ukrainian ethnic land national majority national minority nationstate nonconformism counterculture sixties dissidence ukrainian diaspora etc • a b s t r a k t • w artykule omówiono koncepcyjne i teoretyczne podstawy badania społecznokulturowych procesów w środowisku tytularnego narodu usrr w latach sześćdziesiątych i siedemdziesiątych xx wieku artykuł przedstawia analizę kategorii teoretycznej pojęć narodu tytularnego i rdzennej ludności w usrr identyfikowanych przede wszystkim z ukraińcami których łączyły jeden język wiara duchowość tradycje narodowe zwyczaje wielowiekowa kultura pochodzenie etniczne i pierwotne miejsce zamieszkania na terytorium ukrainy którego oficjalna nazwa została określona przez ich narodowość elementami koncepcyjnymi proponowanego badania są analizy następujących pojęć ukraiński etnos ukraińskie terytorium etniczne lub ukraińska ziemia etniczna większość narodowa mniejszość narodowa państwo narodowe nonkonformizm kontrkultura lata sześćdziesiąte dysydencja ukraińska diaspora itp badanie koncepcyjnych i teoretycznych podstaw podjętego w ramach pracy tematu umożliwiło rozstrzygnięcie szeregu kontrowersyjnych kwestii które nie znalazły jeszcze odpowiedniego pokrycia w naukach historycznych a zarazem pozwoliło określić proces narodowej ekspresji ukraińców poprzez przestrzeń kulturową i otworzyło przestrzeń dla uzyskania nowych ocen osądów i wniosków słowa kluczowe naród ukraiński ukraińcy etnos ukraiński autoafirmacja narodowa świadomość narodowa teoretyzowanie pojęcia argumentacja the aim of the article thus the focus of this article is the study of the conceptualtheoretical foundations fundamental principles of the study of sociocultural processes in the environment of the titular nation of the ukrainian ssr and the selfaffirmation of the ukrainian nation during the 1960s and 1970s the main material and justification of study results the urgency of the processes of the ukrainian nationbuilding and the struggle for the revival of the statehood of the ukrainian people during the 1960s1970s requires a description of the legal basis for ensuring the rights and freedoms of a person a nation in the world and the ukrainian ssr in particular among a large number of published documents in this context one should single out documents of an international regulatory nature namely declarations conventions and pacts that promote the democratic principles of the development of each nation and were ratified by the relevant bodies in soviet ukraine for example it is necessary to mention the un statute some provisions of which were written in collaboration with ukrainians first of all those concerning general respect and observance of human rights regardless of race nationality sex and religion it is also worth emphasizing several conventions in particular the un convention on the prevention and punishment of the crime of genocide which was ratified by the president of the verkhovna rada of the ukrainian ssr in 1954 and on the elimination of all forms of racial discrimination ratified by the president of the vr of the ussr in 1969 another important document is the general declaration of human rights which defined and enshrined the basic rights of man citizen people and nation the international covenant on civil and political rights and the international covenant on economic social and cultural rights are of great scientific value the latter of which has indicated the states duty to ensure the freedom of the individual it needs for research and creative activity recognized the benefits of international contacts and cooperation in scientific and cultural spheres among the legal documents is the unesco convention against discrimination in education which provided free national development in the field of education for countries in general the international regulatory and legal framework was based on the principles of equality of rights of large and small nations equality of nations freedom of thought conscience and religion it spoke for the free development of human rights in the sociocultural life of the country condemned any manifestations of national discrimination thus the legal force of the above documents opened the free path for ukrainians to implement the provisions mentioned in them however despite the ratification of these documents by the governments of the ussr and the ukrainian ssr the soviet authorities failed to approve the right of ukrainians to their national selfassertion which gave rise to the ukrainian protests against the antinational policy of the communist party it is worth drawing the substantive and semantic content of the term titular nation both in the theoretical and practical sense for soviet ukraine this concept is interpreted as a part of the population of the state whose nationality is determined by the official name of this state at the same time the emphasis is placed on the fact that for the ussr the concept of title can be applied to the nation which gave the name to a certain republic of the soviet state accordingly the ukrainian soviet socialist republic got its name from the dominant ethnicity in the republic ukrainian however during the soviet period ukrainians could be referred to as the titular nation of the ussr only on the formal basis the nationality of the majority of the population and the name of quasistate formation of the ukrainian soviet socialist republic the soviet nation of ukraine did not have fullfledged ukrainian content the russianspeaking and russiancultural beginning was dominant in the ukrainian national space the assimilation policy of the communist party leadership leveled and destroyed the natural rights of the ukrainian nation to dispose of their lives on their land systemic russification in the ukrainian ssr has purposefully destroyed the national identity of ukrainians the ukrainian people as potential stateworkers and bearers of their ethnic features in particular language culture traditions and way of life had to disappear the russian leadership was well aware that in the absence of the legitimate owner of the state it could claim its role the communist ruling elite did everything to ensure that ukrainians did not enter their legal status as a stateforming titular nation this state of affairs did not allow the ukrainian people to take advantage of its quantitative advantage in the formation of republican state bodies and institutions of state administration which would organize national security and free national development for ukrainians soviet ukraine which was officially considered a state was not such its statehood was purely formal the ukrainian soviet socialist republic was part of a single unitary state the ussr the ukrainian ssr was a marionette quasistate a statelike pseudoformation formed in an illegal stateforming way soviet ukraine did not have its state borders armed forces and monetary units the anthem coat of arms and the flag of the ukrainian ssr were not attributes of statehood but acted only as masking of the actual colonial status of ukraine as a part of the ussr soviet ukraine did not act as a fullfledged subject of international law and could not carry out independent foreign policy the ruling communist party of ukraine in the ukrainian ssr did not take any independent decisions it was so to speak a subsidiary structure of the cpsu its regional organization and fully subordinated to the latter the same applies to the government of the ukrainian ssr which was a decorative body that created the illusion of labor power the communist governments in the ukrainian ssr were completely dependent on moscow and in their activity were guided exclusively by the instructions of the cpsu it is worth noting that the constitution of the ukrainian ssr did not express the national composition of ukrainians but was a tracing paper of the allunion russiancentric constitution of the ussr in the soviet union the ukrainian ssr was deprived of the right to national sovereignty embodied in the form of state sovereignty thus the state space of the ukrainian nation was taken over by imperial and pseudoukrainian quasistate governments and institutions however ukrainians understood themselves as the only people who naturally and under all international covenants had the right to selfsufficient existence the representatives of ukrainian ethnic who made up the majority in the ukrainian ssr during 1960s and 1970s demonstrated their national maturity through culture which laid the foundation for further struggle for the political independence of ukraine the author supports the view that the titular nation is the dominant most important group that is the national majority which is the leading entity of the state creation its language and culture are the basis for any state the latter for its part is synonymous with the titular nation and must take care of its comprehensive 102 h i s t o r i a i po l i t y k a • n o 4 4 2 0 2 3 papers development in its policy in this context we are talking about the national state according to the place occupied by the nation in the state the author proceeding from the division established in scientific discourse allocates other types of nations first the state nation is a nation that has its own national mostly monoethnic state second the nonstate nation is a nation that does not have its national state or has lost it in the past and is a national minority in another national state third the imperial nation is a dominant nation which will ignore other nations or national minorities under it the last type of nation performs imperial expansion violent assimilation ethnic cleansing deportation and other radical methods at the level of chauvinism and feelings of own superiority the russian nation is the imperial nation which in the process of state policy of the ussr acted as a subject of assimilation of other nations particularly ukrainian ones including through the sociocultural space the rule or dominance of one ethnic community in the state is interpreted as an ethnocracy in the scientific world several interpretations of this term are common firstly as the domination of the elite of a certain ethnic group over other peoples and secondly as a form of political power under which economic political social cultural and spiritual processes are managed based on the monopoly of the ethnic interests of the dominant ethnic group as opposed to the interests of other nations and peoples etc according to the researcher s boyko ethnocracy pursues ambitious political goals which boil down to the fact that their nation is dominant over other peoples which in turn generates national crises and leads to the emergence of interethnic conflicts the outlined trends were followed in the ukrainian ssr during the 1960s and 1970s as a result of conducting russiancentric ethnopolitics the issue of basic survival and the preservation of the ukrainian nation became particularly acute in theoretical approaches to the study of ukrainians of the ukrainian ssr the central place is occupied by the definition of indigenous people which based on a statement established in scientific circulation is interpreted as people living in a multiethnic society of a certain country and being the descendants of those who inhabited this country from time immemorial or in the period of its conquest or colonization or during the establishment of existing state borders the author equates the concepts of titular nation and indigenous people in the ukrainian ssr primarily with ukrainians who were united by a single language faith spirituality national traditions customs centuriesold culture ethnic origin and ancient residence on the territory of ukraine the official name of which was determined by their nationality consequently the ukrainian nation is characterized by a certain set of national features that unite it and distinguish it from other nations speaking about ukrainian ethnos it is worth emphasizing the concept of ukrainian ethnic territory as the main feature of the territorial organization of the ukrainian ethnic community the author supports the scientific point of view according to which ukrainian ethnic territory or ukrainian ethnic land is interpreted as a space compactly inhabited and mastered by ukrainians for many centuries that is the ethnic territory of ukrainians in our opinion should be considered the settlement area of the ukrainian ethnic massif as the main feature of the territorial organization of the ukrainian ethnic community at the same time based on scientifically established statements the ukrainian ethnic territory should be divided into solid in the national structure of the population which is dominated by ukrainians and mixed in the national structure in which the number of representatives of the ukrainian ethnic group reaches half of the total number of all those who inhabit it the majority of the ukrainian ethnic territory of 1960s1970s had a distinctly monoethnic ukrainian character however along with the ukrainian ethnic group many other ethnic groups did not identify themselves with ukrainians according to the definition of representatives of nonukrainian ethnic groups the term national minority should be used it should be emphasized that in some cases ethnic minorities become the subject of assimilation of the indigenous ethnic group for example during the 1960s and 1970s russians as a national minority became the basis of the assimilation processes of the titular nation of the ukrainian ssr as evidenced by the policy of russification which was based on the encroachment of the russian nation on the linguistic and cultural identity of ukrainians in studies on ethnic problems the concept of assimilation is interpreted as the process of the gradual dissolution of an independent ethnic group or its part among a larger ethnic group or group of ethnic groups the assimilated ethnic group loses its characteristic features primarily language traditional culture spirituality and ethnic selfawareness and adopts ethnic stereotypes of another ethnic group assimilation can occur through the voluntary gradual assimilation of ethnocultural traditions of one group by another however forced assimilation is also distinguished which ignores ethnic systems creates all kinds of obstacles to the normal functioning of other ethnic groups and causes devastating political and spiritual destruction to the peoples that have come under its harmful influence the last type of assimilation is essentially similar to the process of deethnicization the dispersal of the ethnic group the destruction of its ethnic characteristics and as a result its complete subordination to the dominant nation deethnicization papers usually begins with the loss of ones native language faith national memory and further ethnic identification all this in the end can ultimately lead to a complete transformation of ethnic selfconsciousness up to its absolute extinction such a consistent and total assimilation was carried out by the soviet authorities in relation to ukrainians the territories of the ukrainian ssr were inhabited by nonethnic elements mainly of russian nationality which led to radical artificial change in the composition of the indigenous population the process of denationalization of the titular ethnos was carried out quite intensively and was expressed in the mass absorption of ukrainian national culture by russia silencing the national mentality of ukrainians assimilation processes in the ukrainian ssr were aimed at eliminating the national characteristics of ukrainians and instilling in them the ethnic characteristics of the great russian people such a course of events was inhumane in addition to the internal processes of assimilation of ukrainians the transformation of the ethnic structure of the ukrainian ssr was also influenced by external migration processes which gained significant intensity during the soviet period of ukraines history separated from mainland ukraine ukrainians formed the ukrainian diaspora which is characterized as an established group of people of the same ethnic origin living in a nonethnic environment outside the historical motherland the ukrainian diaspora was one of the largest diasporas in the world whose representatives lived in many countries on the territory of several world continents therefore outside the area of settlement of its people for the preservation reproduction functioning and development of its community it always formed many social cultural and educational centers at the same time ukrainian emigrants sought to preserve their ethnic identity and maintain close ties with ukraine the interrelationships of the diaspora and ukrainians of mainland ukraine can be traced to the 1960s and 1970s during the period of active manifestation of the desire of the titular nation of the ukrainian ssr to preserve and demonstrate national i to the world ukrainians who led the struggle for their national distinction in the scientific world were called dissidents it was they who personified the democratic type of personality that valued the human right to freedom and reacted sharply to the attempts of the totalitarian machine of the soviet state to limit it speaking about the oppositional moods in the ukrainian ethnic environment at that time it is advisable to find out their definitions which in the scientific literature fall under the concepts of nonconformism counterculture alternative culture shadow culture sixties dissident etc the concept of nonconformism is defined in the scientific terms of political science psychology philosophy cultural studies and other sciences the varieties of this phenomenon in the field of culture include literary and artistic nonconformism which can be considered through the prism of counterculture which is based on opposition to the fundamental principles of officially recognized culture in this context counterculture converges with the concept of alternative culture in domestic historical science the term nonconformism is considered to denote the activity of the intelligentsia of a new generation of ukrainian artists who in the early 1960s brought the spirit of rebellion and denial of official established dogmas to soviet culture in several studies on the mentioned issues the definition of shadow culture is found which involves promoting unauthorized works producing silenced plays advocating alternative judgments etc also it is possible to talk about nonconformism and disagreement with the generally accepted form of artistic thinking it is worth noting that the nonconformist phenomenon in the ukrainian ssr was also the sixties which was represented by strata of ukrainian nationally conscious intelligentsia which appeared in the cultural space of the ukrainian ssr in the second half of the 1950s during the time of destalinization and a certain liberalization and manifested itself most creatively at the beginning of the next decade and in the mid1960s for the first half of the 60s of the 20 th century it is quite appropriate to use the term nonconformism in parallel with the use of term sixties however to characterize the subsequent course of events in the ukrainian ethnic environment the concept of nonconformism decreases its significance since the second half of the 1960s given the mass persecution and repression of ukrainian human rights defenders the oppression of the national cultural and spiritual life of ukrainians and the violation of constitutional rights and human freedoms by the ruling communist leadership dissident circles have resorted to more active forms of protest against the then government in the outlined period the formation of ukrainian dissidence took place the characteristic feature of which was the struggle for the national interests of the ukrainian people which combined the most diverse forms of civil protest from intellectual resistance to the creation of organizational structures for the overthrow of the existing soviet state system papers a dissident can be characterized as a political dissident a member of the opposition movement given the above the relationship between the concepts of nonconformism and dissident is inappropriate thus w parchomenko believes that the specified concepts are completely incomparable since nonconformists are characterized by a more passive retreat from official standards of behavior while dissidents are characterized by more active resistance to the ruling regime already in the political plane conclusions thus the conceptual and theoretical foundations of the proposed research are based on the achievements of many social sciences including history ethnology cultural studies political science demography economics ethnostate formation etc each of the above concepts is not ideal but has its advantages and disadvantages however it is their balanced combination that remains a reference point in the study of the history of the ukrainian people of the second half of the 20 th century the study of selfassertion of the ukrainian nation in the defined period the study of the conceptual and theoretical foundations of the proposed topic made it possible to systematize and generalize the information obtained while avoiding subjective assessments and helped to approach the most objective scientific assessment of the dynamics trends and consequences of social and cultural processes in the ukrainian ethnic environment of the ukrainian ssr during the 1960s1970s period ensuring the scientific reliability of the obtained research results

h i s t o r i a i po l i t y k a • n o 4 4 5 1 2 0 2 3theoretical thinking involves the principles on which certain research is based and allows historians to develop and improve their argument elevating scientific research and its results to a significantly higher level to cover a particular historical topic comprehensively researchers should pay their attention to the diversity of scientific theoretical approaches balance their principles and understand their cognitive potential and the framework of the restrictions with the independence of ukraine democratization of sociopolitical life opening access to many archival sources favorable conditions were created for free unbiased methodologically and theoretically balanced study of the soviet past of the ukrainian nation without theoretical thinking scientific concepts and historical studies are doomed to become only a logical collection of facts therefore the importance of a careful attitude to the theoretical foundations of historical studies always remains relevant

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introduction military firefighters are perceived socially as a brave and fearless superheroes always ready to help and save lives however the reality of the activity of these workers includes the demands of any other worker aggravated by the strict military hierarchy exposure to risk situations and intense work rhythm 1 they live in constant physical and psychic overload routinely deal with tragic situations predisposing themselves to high levels of tension threats and anxiety often in unprecedented and unexpected situations with exposure to all types of risk also risking their lives 2 however one tends to think of these professionals only as caregivers and hardly as individuals also requiring care and who may have their health compromised 3 the relationship between the healthdisease process and work of this category still has little prominence in the national scientific literature 1 4 5 6 this situation is more pressing when we find a lack of studies that consider firefighters working in prehospital care 5 prehospital service is a peculiarity in urgent and emergency care since it means a type of care that transcends the conventional physical environment of health facilities 3 the professionals of these services work daily in adverse unknown and unpredictable environments with neither routine activities nor control of the time spent in each occurrence thus hindering their time management also a particular feature is found in the municipality of rio de janeiro where the emergency mobile service has been administratively integrated into the fire department since 2007 and has assumed operations and implementation since 2008 this is a functional differentiated situation because workers are military unlike what happens in the other samus of the country whose service is manned by civilian workers 7 since joining the fire department samu has increased the rates of service to the population 8 the capital of rio de janeiro accounts for about 70 of aph 9 according to data from the statistics section of cbmerj the fire department attended approximately 337060 distress calls in 2015 of which 173532 were performed by the units of the capital of these 7930 were for fires 30696 rescues and 134906 for prehospital care 1 according to the 2016 cbmerj yearbook 10 348568 military fire services were carried out in the state of which 148661 were carried out by the aph when compared only between the rescue modalities this percentage rises to 558 translating into 412 daily attendances around 320 attendancesday are estimated in the city of rio de janeiro over the years a large number of attendances coupled with poor working conditions have generated high rates of dissatisfaction suffering and illness of the category it can be said that poor conditions have become the foundation of contemporary work organization exerting a disruptive influence on human and social relationships in and out of work these ruptures stem from the competitiveness engendered the imposed polyvalence excellence intimidation moral harassment and other forms of violence culminating in suffering and illness in individuals reaching the extreme situation of suicide often in the workplace itself 11 12 13 one of the manifestations of military firefighters dissatisfaction is evident in existing blogs currently two blogs represent cbmerjs military firefighters and serve as sources of dissemination organization and debates about the needs of the category these spaces emerged from the demands of the military firefighters of the state of rio de janeiro initiated in april 2011 in the fight for decent working conditions and better salaries at the time the lowest in the country aware of possible reprisals and punishments comments are predominantly anonymous these spaces allow users more freedom of expression and participation and are recognized as a new model of representative democracy and political participation given that the internet has been the leader of political manifestations in the world 14 since the end of the twentieth century furthermore blogs represent a reconfiguration of traditional media by creating new opportunities for social interaction the blogosphere consists of independent bloggers who have created their networks and promote debates discussions collective actions outside the corporate media or sizeable traditional portals 14 montardo and passerino 15 affirm that posts are at the core of the blog in which bloggers set their reflections and visitors post comments and opinions about the subject posted according to the authors a communication mediated by computer postings is an essential and reliable observation mechanism thus this study proposed to analyze the relationship between work and health of the military firefighters working in rio de janeiros mobile aph with particular attention to the meaning of work from the interactive activity of blogs sos bombeiros and sos bombeiros rj material and methods an exploratory and analyticaldescriptive study was conducted with a quantitativequalitative approach in two virtual communities of the subcategory of blogs sos bombeiros through the electronic address and sos bombeiros rj through the link without any priority order the sos bombeiros blog was established in 2011 it has recorded 8641077 hits since its inception and has a representation of 6044 thousand followers in its extension to facebook the blog sos bombeiros rjwas established in 2012 it has recorded 6435548 hits and has 14371000 followers on its official facebook page data collection data were collected using the importio software that runs on websites performs the automatic extraction of a large volume of data and converts them into structured analyzable data blogs posts were searched by keywords and the by date filter of published material from 2011 to october 2017 was applied considering that these blogs address various topics of interest to the entire firefighters category and some are more specific to particular segments of the fire brigade four keywords were established for search in order to recover only the material that addressed matters relating to the aph service aph ambulância gse and samu selection criteria after the initial collection screening was carried out to select only the subjects that dealt with subjects related to the mobile aph service of the municipality of rio de janeiro from the keywords described in data collection those that emerged in the search terms but were not related to the search object were excluded following the selection of the subjects data were tabulated in a spreadsheet and identified through the fields position date paper title link to the paper number of comments in the post and if exclusive of the mobile aph of rio de janeiro thus it was possible to identify the most influential subjects among bloggers observing the inclusion and exclusion criteria establishing the corpus with the most influential blogs at hand the next step was to assemble a corpus with the comments inserted in the four posts with the highest number of comments the selection of the sample was by the criterion of saturation of recurrence of words and volume of data a corpus is nothing more than a collection of texts that shows a set of natural languages and establishing this set is a timeconsuming task since in most cases manual processes based on the knowledge of a specialist are required 16 for this study four corpora were assembled in plain text files using a text editor after building the corpus a preprocessing was required before running the experiments in the data analysis tool this step primarily aims to clean data eliminate redundancies and unnecessary information 17 the main techniques applied in this stage considering textual databases derive from computer science through text mining which will not be considered in this study because they are not part of the scope except for stop words stopwords are common words that frequently appear in texts but are semantically irrelevant that is they have no value for analysis these words are represented by articles prepositions pronouns conjunctions and punctuations also excluded were month names dates numbers and words blog reply and comments it should be noted that the choice of stop words will result from what we intend to analyze and that some words considered stop words may be significant depending on the context data analysis voyant tools was used to extract characteristics of the corpus assembled in the previous step it is a web application that facilitates exploring opportunities of analysis of text through algorithms that calculate the frequency of terms used the distribution and relationship between words the patterns of relationships through quantitative analyses and graphic representations results and discussion the implementation of the search string in blogs returned a total of 280 posts distributed between 2011 and october 2017 the filter applied through the inclusion and exclusion criteria occurred in the following sequence a reading the title of the material b excluding duplicated material in the same blog c excluding duplicated material between the two blogs d reading the full text and e excluding subjects that did not meet the selection criteria reducing the initial corpus of the research to 75 subjects table 1 summarizes the number of items obtained with search sessions during the process of selecting the materials aiming to select only those that approached the mobile aph service we found that they mostly addressed aph servicerelated issues with some exceptions however they did not consider exclusive guidelines of rio de janeiro since it is a state institution among the matters excluded were those that addressed matters such as aph from other municipalities of the state matters of general interest to firefighters matters specific to other firefighters segments policy and state management the subjects related to the object were organized in four categories based on the title theme and subject of comments work organization working conditions information and dissemination and recognition work organization the main guidelines of debates about this realm of work were gse samu linkage hierarchy subordination harassment and penalties working conditions urban violence physical environmental and psychic risks remuneration leave accumulated functions food and hygiene conditions precarious ambulances lack of vacancies and beds in hospitals information and dissemination a paper comparing samurj with samusp another disseminating a reality show that would accompany the routine of samu rio professionals and a call for a meeting with samu rio professionals recognition refers to a matter called gse of firefighters decisive service to save lives in which the corporation shows the rate of attendances and says that capital of rio de janeiro accounts for almost 70 of the states aph and describes the relevance of the service for the outcome of accidents trauma and clinical events 9 the acknowledgment in this post is related to the statistics of the attendances without mentioning the professionals but it is understood as being appropriate to them since there is no work without workers at various times firefighters are grateful for the recognition of the population and media support paradoxically they challenge the lack of recognition of the corporation either by acknowledgment praise or promotion the interactive activity in blogs was analyzed using the voyant tools to meet the research objectives taking as reference the four subjects with the highest number of comments on the topic addressed in this study the story with the highest number of comments the face of inhumanity within the cbmerj is the case of a nurse officer working in a samu ambulance who after several occurrences claimed to no longer have the physical and mental conditions to continue in service even under higher orders the professional maintained her refusal justified by her health status through such stance when returning to the barracks she was jailed due to insubordination the subject had great repercussion among firefighters but among the various manifestations of support some concerns that put in question the professionals conduct were raised rodrigues and bellini 13 described that a worker who is ill due to work situations suffers both from physical or mental impairment and prejudice of commanders and even colleagues due to lack of knowledge or access to workers social rights and health firefighters participating in the study by monteiro et al 18 reported that society and the community itself believe that firefighters cannot show fragility and must bear everything mainly because they are military and because there is no opportunity for listening oftentimes they do not complain for fear of criticism and comments from colleagues there was also great mobilization of the nursing category and health professionals in general including other social media such as facebook whose story had 4036 reactions through standardized figures to express users emotions known as emoticons 548 comments and 1251 shares this was not different in the firefighters blogs inhuman we have reached our physical and mental health limits anonymous january 9 2017 09 21 min this is cowardice an unfortunate situation when we enter the corporation we arrive full of spirit and will but the working conditions drive us sick anonymous january 9 2017 00h43min the theme of the second story is the arrest of a male health military according to the report at the end of the shift a corporal deployed as a nursing assistant was informed that he should work a doubleshift because his ambulance replacement did not show up the worker justified that he was exhausted following several attendances and did not have the physical and emotional strengths to complete another 24 hourshift in addition to personal issues however despite explanations the military was arrested due to insubordination is arresting an exhausted family man after completing his workday complying with the regulation anonymous february 6 2014 150 pm the third story questions the extraordinary compulsory work schedules in the gse in addition to the outrage due to successive salary and 13 th salary arrears claiming not to have the financial resources to travel from the residence to the barracks and vice versa the dream of any top gse military is to leave the gse the gse military is not entitled to leave is not entitled to health is not entitled to family is not entitled to leisure is not entitled to have rights is not entitled to life we are worthless spare parts to those who command us anonymous december 23 2016 1012 am the last story addresses the report of a distress call sent by a health firefighter in this report the worker describes the working conditions experienced by ambulance professionals claiming to be subjected to poor working conditions without rest and conditions to fulfill his basic needs without recognition for work accumulated leaves to be taken and work overload after linking the samu to the gse as reported below i am here to ask for help from the sos because i cannot stand the lack of consideration with the military who are already tired of giving away years of their life to aph rescue calls in cbmerj ambulances and also accumulating samus work excerpt from the firefighters report on working conditions january 7 2014 the four databases were loaded simultaneously forming a single file thus the cor pus consisting of the four documents contains 31941 words and 5894 unique word forms that is words that were not repeated in the text the most frequent portuguese keywords in the corpus are samu serviço gse militar and cbmerj although the words bombeiro and bombeiros are also recurrent in the comments they were not considered synonymous due to the semantic value bombeiro mostly refers to the firefighter subject bombeiros appears as both a subject and a combination of corpo de bombeiros quartel de bombeiros and so forth since the tool understands each word as unique the same goes for the words militar and militares the word cloud configuration allowed us to identify the most frequent terms which are more centralized and in a larger font the classification of the most frequent words shown in the cloud configuration allows us to visualize the fundamental concepts within the context of the aph rio service possibly a similar analysis in a fire department blog of another state the term samu would not be the most incident the respective acronym is the central element in the discussion of the firefighters linked to the gse in which the samu is administratively inserted these workers claim that increased service and work overload was noted by linking samu to the cbmerj according to reports in blogs narrowing of schedules increased number of attendances extraordinary schedules increased exposure to physical environmental and psychosocial factors among them the increased number of accidents and urban violence in communities with high levels of violence because they suffer threats from traffickers due to their military status however despite the increased demand and workload of aph rio firefighters there was no wage increase much less more workers since the last contest that included every health category was in 2008 and there is no forecast for new competition according to law nº 6170 of march 5 2012 19 cbmerjs workforce was fixed at 23475 military firefighters that is it should consist of this amount for a population estimated at 16273984 inhabitants that year in 2016 the population estimate of ibge 20 was 16635996 inhabitants establishing a correlative analysis the actual estimate should be 25194 firefighters however according to data from the 2016 cbmerj yearbook 10 the number was 14797 active military personnel resulting in a proportion of 1124 inhabitants per firefighters and a shortage of approximately 10397 firefighters considering the estimate of 1200 health professionals in the gse 9 the deficit of this cadre would be around 843 workers or almost double of workers the ratio between the number of attendances and the number of active firefighters shows that around 8 of military personnel are allocated in the aph and account for 42 of all state production in the capital they are 6 and they perform almost 30 of all the attendances and work overload of firefighters working in the mobile aph of the state and municipality of rio de janeiro is evident decentralization automatically uncoupling the samu from the gsecbmerj would not only reduce the demand and work overload in the group of firefighters but also physical and psychosocial harm such as depression burnout gastrointestinal and cardiovascular disorders rsiwmsd accidents and so forth unlinking would also promote an higher supply of jobs favoring many currently unemployed workers as well as affecting the economy of the municipality and state with no excess burden on public coffers since the compensation of firefighters is already the responsibility of the state manager and there is a monthly financial incentive transferred by the ministry of health for the cost and maintenance of the program and according to the guidelines of the national policy 2223 there must be a counterpart of the state and municipality on a regular and agreed basis of the other 50 in fact there is a sum of errors on all sides the samu cbmerj military compete on an absurd work schedule given the service demand there are no working conditions as many vehicles do not even have air conditioning apart from the disrespect concerning mealtimes and physiological needs as well as the limit of the body itself anonymous january 8 2014 1343 several realworld structures can be represented through graphs facilitating relevant information about their elements and their interactions in a network a graph is formed by nodes or vertices connected by lines called edges or links and that establishes the relation between them 24 in network analysis centrality is the measure of the importance of a vertex in a graph and the different metrics allow to estimate the influence of a stakeholder or element within a network several studies have used networks for text analysis in which words are the nodes and the edges the links between them 25 the representation of text in a network facilitates categorization of textual data identification of the most influential terms detection of closely related concepts in a word community retrieval of hidden agendas within a text and perception of feelings allowing the construction of meanings 25 the graphic configuration of links is determined by the degree of proximity between words and expresses in a didactic and succinct manner the main topic of debate in the context studied the words samu service and gse have the highest degree of centrality in the text corpus and work as mediators in the construction of meanings adjacent words are the most frequent words in the context of keywords corroborating previous data we can see the centrality of the word samu however different from the cloud we can see beyond frequency the interaction between words the highlighted words are the most influential in the text consequently in the statements the word serviço is directly related to the words absurdo militar bombeiro samu andvtr gse is immediately related to militar cbmerj fim militar and samu and the word samu to gse serviço cbmerj and fim the analysis of the network in dialogue with the materials and comments confirms the study by salvador et al 5 whose firefighters from the city of rio de janeiro declared that the primary work stressor is the integration of samu to the military fire brigade claiming work overload and attendance of nonurgent and nonemergency demands hampering service to the real needs of the population campaign down with samu for a minimum of dignity to the health of the cbmerj worker we need to help each other together we are strong msilva january 8 2014 1026 pm emphasis added i cant stand this work routine anymore ive been on sick leave several times because of health problems several friends are on sick leave due to health problems this is absurd it has to stop we cannot take it anymore down with samu jsf december 23 2016 1103 an interesting function provided in the tool is the measure of correlations which calculation is based on the correlation function created by pearson 26 and facilitated a deeper understanding of the corpus this study does not pretend to be exhaustive regarding pearsons correlation briefly the correlations function allows to evaluate when two variables have some relationship between them that is whether high values of one of the variables imply high values of the other variable for example one can verify whether there is an association between the birth rate and unemployment in a city among the financial resources invested in condom use advertising in the correlation analysis we attempt to determine the degree of relationship between two variables that is to measure the variability between them a coefficient close to 1 indicates a positive correlation scores close to 1 mean a negative correlation that is frequencies of a term vary inversely coefficient close to zero indicates weak or negligible correlation 20 in figure 3 we can see a strong correlation between some words among which the tool classified in descending order of correlation by verifying the words with the highest correlation index it can be inferred that in most of the comments in which the word trabalho was used the word vítima was also used whether in the same comment or the next it was necessary to go directly to the comments and verify at what point they were used to check the information and validate the toolgenerated result words trabalho and vítima appeared concomitantly in two contexts 1 after a comment about the work and the victims and 2 sometimes referring to firefighters as victims of their work you dont solve anything and you even shift from victim to culprit words serviço and tirar compete in two moments 1 when they are referring to the activity ofreplacing someone and 2 in questionings about work and impossibilities of taking leave rest schedule etc the military is coerced to perform an extra service to take leave words dinheiro and militares also appear in two circumstances 1 when they question why the resource transferred by the ministry of health to samu is not used to remunerate them through extra work and 2 they mention the lack of money to commute to work and other needs as a result of various pay andor bonus payment in arrears they bleed preparedness by saying that they do not have money to go to the barracks to work their shift imagine the situation in prog which doesnt pay words acabar and direito alternate dialectically in discourses users question when this management model ends a bond that as they say brings consequences to work and health at the same time they question their rights in short they claim the workers right to health and better working conditions they dont respect the right to leave and others when will this end the correlation chart made a significant contribution to work by showing that it is possible to seek knowledge in blogs and through the association between words to be able to understand some aspects of reality however in this research in two moments it was not possible to establish an adequate correlation between the associations shown in the chart words menos and somos the word menos does not have precise semantic value and can be used as adverb noun pronoun preposition among others somos usually appeared to mean collective identity or plurality however making an empirical inference these suggest a disregard for various interests of the community or the reaffirmation of the communitys strength in the face of deprivation or subtraction words causa and público it was also not possible to draw up a coherent correlation the word causa usually appears as a consequence of something for example work demotivation arising from work organization while the word público is a component of the term ministério público and is repeatedly mentioned as the legal means of filing a complaint and appeal to the firefighters rights according to paranyushkin 25 the organization of related terms is based on affinity causal relationships chronological sequence and semantic analysis however the computational interpretation does not apprehend subjective and cultural questions in the graphic structuring of the texts since it is the result of a negotiation with the text itself there is also an orthographic limitation since a compound word is not apprehended as a unique term but as two distinct words final considerations the study showed that although firefighters are socially recognized as heroes and one of the professions most praised by the population this recognition does not seem to reflect on the working and life conditions of the mobile aph military firefighters of rio de janeiro the analyses of the subjects and discussions revealed uncomfortable situations in the work environment among them military rigidity moral harassment physical and mental overload violence among others while many refer loving their profession these situations have had repercussions on dissatisfaction suffering and sickness of these workers as a consequence of organizational and working conditions enhanced by the linkage of samu to the gsecbmerj blogs act as a new political stakeholder in social relationships and have shown their potential for building knowledge and understanding of meanings with elements that can be transformed into realities the representativeness and relevance of blogs analyzed for the firefighting community under the motto together we are strong have contributed to the organization information debate and struggle of these workers for better living health and work conditions the transition of communication and information to the computerized environment while quite advanced often surprises us the social relationships created in the virtual networked environment often show us an innovative perspective that requires indepth analysis like other networks blogs are environments of intense social participation and an efficient way to communicate ideas articulate actions mobilize people and so forth the results revealed some interesting findings on some of the needs of the aph rio military firefighters these results bring relevant contributions to other researchers who investigate the patterns and behaviors of people in the virtual environment and in society itself their findings also suggest new studies to better understand the administrative and financial covenants of the linkage of samu to gsecbmerj as well as provide fundamental elements to reconsider health governance strategies and actions in the state and municipality of rio de janeiro there is evidence of the need for institutional recognition of the category and public competition based on the overload and shortage of professionals since the last public competition that included the entire health category dates back to 2008 it is imperative to elaborate a continuous psychological monitoring service for the aph rio firefighters and increased attention to the health of these workers of course this study has limitations voyant tools produces a series of information about the corpus and has a limited collection of metrics bracketing possibilities of analysis moreover despite the merit of being an exploratory study the nature of the computerized model restricted further analysis of singularities of firefighters work which essence is the relationship with the other suggesting new investigations in dialogue with other study methods collaborations ma oliveira was responsible for defining the theoretical framework planning conducting the research and paper drafting emn brito was responsible for the empirical material analysis methodological review and paper drafting s oliveira participated in the overall orientation of the research and contributed to the structuring and final review of the manuscript

advances in the techniques of automatic document analysis allow the understanding of objectives and subjective aspects in texts extracted from social media this paper proposes a study on the workhealth relationship of military firefighters of the prehospital care in the city of rio de janeiro through publications in the blogs sos bombeiros and sos bombeiros rj thanks to the methodological approach through network analysis a strong correlation between the words used by the stakeholders was uncovered revealing precarious working conditions and the need for increased attention to workers health

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introduction human immunodeficiency virus and acquired immunodeficiency syndrome are a major global public health problem the worldwide efforts to manage the hiv and aids pandemic have been increased because the virus is spreading with greater speed in 2012 about 334 million people were living with hiv worldwide in december 2014 in pakistan an estimated 91 340 people were living with hiv and another 15 606 were newly infected with hiv the overall prevalence of hiv among 1549yearolds in pakistan was 08 the main modes of hiv transmission reported in south asia and pakistan are sexual transmission and reuse of contaminated syringes in south asia individuals infected with hiv are usually unaware of the disease and unable to detect symptoms in the early stages before diagnosis and seeking proper health care patients may have already received health care from spiritual or faith healers which delays diagnosis and proper treatment this lack of awareness of the disease results in the majority of hivinfected persons not seeking medical help until the condition has worsened leading to various complications of hiv treating the disease at this stage with causes a financial burden to the individual and family and this has been reported as a major constraint in seeking proper medical care the accessibility to services information and educational initiatives concerning hiv and aids does not guarantee access of a person to proper treatment healthseeking behaviour of an individual determines their approach towards receiving proper treatment for a disease research on cultural aspects supports the importance of knowledge regarding the disease and the healthseeking behaviour of patients according to a study conducted in india on 160 hivinfected patients selfmotivation for hivaids medical treatment was found in only 38 of the patients other significant factors related to the hivinfected person and their access to treatment reported in the study were lack of information prejudice and an unsupportive attitude of health care providers unavailability of a patients medical historyreports from previous consultations legal status and use of traditional medicine it is therefore important to determine the healthseeking behaviour of hivinfected persons and their satisfaction with the health services provided so that their needs and preferences can be better addressed previous research studies in pakistan have been conducted on knowledge attitude and practices regarding hiv aids prevalence and risk factors of hiv aids and education and counselling regarding hiv aids but none has looked at the healthseeking behaviour of persons living with hiv the present study therefore aimed to assess the healthseeking behaviour of persons living with hiv at a tertiary care hospital in karachi pakistan and their satisfaction with the health care services provided methods study design and setting this was a crosssectional study conducted in the hivaids clinic of the civil hospital karachi pakistan from august 2013 to february 2014 the civil hospital is a 1 900bed public sector tertiary care teaching hospital providing health care services to people of sindh and baluchistan about 5000 patients have been registered in the hivaids clinic and daily turnover at the outpatient clinic is about 50 patients the clinic offers registration of hiv patients follow up in the outpatient clinic treatment and laboratory facilities sample size and sampling the population of interest consisted of both male and female people living with hivaids over the age of 18 years attending the hivaids health care centre of the hospital the study participants were enrolled in the study through purposive sampling the sample size of 182 was calculated using the equation pd 2 assuming a proportion of selfmotivated healthseeking behaviour of 138 with 95 confidence interval and 5 margin of error data collection and tools a questionnaire was designed in english translated into urdu and then backtranslated to english to remove any language ambiguities it was pretested in a similar setting on 15 of the sample size population the questionnaire was administered in urdu by the principal investigator information was collected on sociodemographic variables healthseeking behaviour and satisfaction level with health care services the information about healthseeking behaviour was collected by asking 15 questions each question was scored as positive healthseeking behaviour and negative healthseeking behaviour each question had 1 mark for a correct answer and 0 for an incorrect answer the cutoff level was 80 a score of ≥ 12 out of 15 was considered positive healthseeking behaviour a score 12 was considered negative healthseeking behaviour similarly the scoring of satisfaction level with the health care services provided was based on 10 questions with a cutoff level of 80 a score of ≥ 8 out of 10 was considered as satisfied a score 8 was considered not satisfied ethical considerations the study was approval by the institutional review board of dow university of health sciences informed consent was obtained from the participants and they were assured of the confidentiality of the information and that their treatment would not be affected if they declined to participate statistical analysis data were analysed using spss version 21 the frequencies percentages mean and standard deviation were calculated for continuous variables in a multivariate logistic regression analysis with the dependent variable being healthseeking behaviour the crude and adjusted odds ratios and 95 confidence intervals were calculated for the independent variables age gender marital status educational status visit cost and duration of hiv aids results sociodemographic characteristics of participants none of the individuals approached declined to participate table 1 shows sociodemographic and healthrelated characteristics of the participants the mean age of the respondents was 3231 years with 714 aged between 3660 years the majority were male and married only 187 were educated but most were employed healthseeking behaviour of the participants out of the total participants 236 had positive healthseeking behaviour only 27 of the participants contacted health care professionals on noticing first symptoms of the disease almost a third of the participants reported the use of contaminated sharp equipment including razors and needles as a possible source of their infection only 88 of the participants reported that they were getting treatment on a regular basis a majority reported that they were facing problems in getting antiretroviral medicines and only 143 received medicine on a regular basis from the health care centre the vast majority had considered going elsewhere for treatment with 280 reporting that they had received treatment from faith healers while receiving antiretroviral therapy regarding sexual contact with their partners in last 6 months 30 participants had had contact with only 2 of these reporting use of condoms most of the participants reported that their family members knew that they were getting treatment for hiv infection the majority responded that people should first consult a doctor if they notice symptoms associated with hiv infection or aids satisfaction with health care facility and staff based on our cutoff value of 8 over half of the participants reported that they were satisfied with the health care services provided to them the majority were satisfied with the overall environment of the health centre but only 159 reported availability of drinking water at the centre and 165 reported that adequate seating arrangements were available slightly under threequarters of the participants were satisfied with the attitude of the hospital staff although 785 reported a communication barrier in discussing the symptoms of disease with the staff less than half of the participants reported that staff answered their queries in detail but 896 reported that they were informed about the next followup visit by the hospital staff almost all of the participants reported that they would continue to receive treatment from the hivaids health care centre of the hospital univariate analysis association of healthseeking behaviour of the participants with sociodemographic and healthrelated characteristics was determined in a univariate analysis healthseeking behaviour was dichotomized as positive and negative according to our cutoff values no statistically significant association was found between age sex marital status educational status employment status and duration of hiv infection and healthseeking behaviour however cost per visit was significantly associated with positive healthseeking behaviour multivariate analysis in the multivariate analysis of the association between the independent variables and the dependent variable positive healthseeking behaviour the cost per hospital visit us 5 and duration of hiv 2 years were significantly associated with positive healthseeking behaviour discussion in our study there were more male than female participants which is consistent with the findings of other studies conducted in pakistan it could be that men are at higher risk of infection than women due to greater exposure to risk factors such as drug abuse and the use of contaminated syringes unprotected sexual activity with multiple partners and unsafe blood transfusion probably because men in south asia have more exposures outside the home it could also be that women do not appear for diagnostic or screening tests and suffer in silence the pakistan global aids response progress report 2015 reported that of the estimated total of 91 340 hivpositive people in pakistan 63 872 were males and 27 468 females giving a male to female ratio of 23 in our study the ratio was 33 so it may be that fewer women are seeking screening and treatment than men the majority of the participants in our study were employed contrary to the findings of a study conducted in peshawar pakistan which found that the majority of the respondents were unemployed a study conducted in argentina on anaemia among aids patients reported poverty and unemployment were significantly associated with being anaemic a study in india on the sociodemographic profile of people with hiv attending a tertiary care hospital for antiretroviral therapy reported that more belonged to low socioeconomic classes as compared to middle and high socioeconomic classes the majority of the participants in our study were uneducated which is similar to the findings in the peshawar study and those reported from other parts of the world level of education is an important factor as it determines knowledge about the disease a study conducted in a postgraduate college of rahimyar khan pakistan reported that knowledge about hiv and aids was greater in students with 13 and 14 years of education as compared to those with 11 and 12 years a multicentre study in spain of an hivpositive cohort reported that a greater proportion of the cohort had a low educational level less educated people were found at increased risk of disease progression compared to more highly educated people and the risk of death was lower among those with a higher education level other factors like early recognition of symptoms utilization of health facilities and compliance with treatment ie healthseeking behaviour are as important and necessary for people living with hiv the majority of our participants with hiv aids showed limited healthseeking behaviour the cost of treatment and duration of hiv infection were the only factors found significantly associated with healthseeking behaviour of the participants the patients paying less than us 5 per visit were about 4times more likely to show positive healthseeking behaviour compared to those who paid more than us 5 per visit the patients living with hiv for less than 2 years duration showed an association with positive healthseeking behaviour studies conducted in india also found that the most common barrier to patient healthseeking behaviour and practice was cost a study conducted on the natural history of hiv in chennai south india reported that half of the individuals who discontinued treatment and then restarted the same therapy had initially discontinued due to cost and 10 of patients stopped treatment within 4 months of initiation due to cost a persons healthseeking behaviour determines their actions when infection is suspected if a person continues to have sexual contact even if heshe has recognized symptoms of the disease then they could infect more people thereby increasing the risk of epidemic selftreatment with antibiotics or other methods is another aspect of health behaviour which affects control of the disease such selftreatment and alternative methods can prolong the period of infectiousness prior to effective treatment and lead to the development of resistant strains social stigma limited surveillance voluntary counselling and testing systems and a lack of knowledge among the general population and health practitioners can affect the healthseeking behaviour of people with hiv and in many countries these can result in underreporting of the disease pakistan has been classified as a lowprevalence country for hivaids but the prevalence is increasing and needs the serious attention of both the public and private health sectors due to the stigma and discrimination associated with the infection the majority of those positive for hiv do not seek further treatment and do not appear in the records to address this problem awareness and health promotion about hiv and aids in the general population is extremely important as is improving the healthseeking behaviour of those living with hiv the successful implementation of health promotion programmes can play a major role in controlling hiv and aids in pakistan there were some limitations to the study the study was conducted in a single aids centre due to limited resources and time and findings can only be generalized to karachi city its design is crosssectional therefore temporal association between risk factors and outcome cannot be established conclusion the healthseeking behaviour of the majority of the hivaids participants in our study was generally poor and half of the patients were not satisfied with the services provided to them the cost of treatment and duration of disease significantly predicted their healthseeking behaviour our study suggests that lower cost and timely treatment should be provided and efforts should be made to improve the healthseeking behaviour of people living with hiv aids funding none competing interests none declared

appropriate healthseeking behaviour is important as it allows prompt treatment for a condition and this can reduce complications and improve quality of life this study aimed to assess the healthseeking behaviour and satisfaction with health care services of people living with hivaids attending the hivaids clinic of the civil hospital in karachi a total of 182 patients were interviewed using a pretested semistructured questionnaire mean age of the participants was 3231 sd 791 years 769 were male 813 had no education and 758 were employed only 236 showed positive healthseeking behaviour and 577 were satisfied with the health care services in logistic regression analysis the cost of treatment per visit us 5 and duration of hiv infection 2 years were significantly associated with healthseeking behaviour efforts are needed to improve the healthseeking behaviour of people living with hivaids at the clinic and the health services offered

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introduction the ahmadiyya adherents often experience threats intimidation and violence in the muslim world including indonesia after the downfall of soeharto social conflict and violence against the ahmadiyya increased tensions arose in many areas including manislor cikeusik and east lombok reaching a peak during the presidency of susilo bambang yudhoyono the tensions have increased even more with the growth of conservative islam adherents whose intolerance toward ahmadiyya adherents has become increasingly apparent despite the peace initiatives discrimination and persecution of ahmadiyya adherents in manislor continue structurally culturally and socially although ahmadiyya adherents are the majority in the village the population is a minority compared to the entire kuningan regency most of the kuningan population is sunni muslim conflicts and violence among religious and ethnic communities were rising during the presidential administration of susilo bambang yudhoyono triggered by the increasing discriminative acts such as stigmatizing the believers of ahmadiyya these several facts are rooted in the inception of the joint ministerial decree issued by yudhoyonos administration data from the indonesian survey institute and kontras recorded 1483 cases from 2005 to 2012 or an average of 210 cases per year the intolerance and persecution of ahmadiyya adherents continued to the administration of the incumbent president joko widodo the results of research conducted by the indonesian national committee of human rights the setara institute and the wahid institute show that local governments both provincial and municipal are the main perpetrators of violations of the rights and freedom of the ahmadiyya adherents to believe and practice their religion previous studies on the conflicts involving the ahmadiyya community in indonesia have shown that they were rooted in theological disputes which were later spread to different levels of society and escalated into violence research has also shown that jihad was used to justify violence toward the ahmadiyya community other studies showed the links between the conflicts with skb and the discrimination against minorities the absence of state the discourse of media in covering religious conflicts the peace process and the fulfillment of the ahmadiyya adherents civil rights under the administration of president yudhoyono there were many civil rights violations against ahmadiyya adherents including withholding the issuance of identity cards and family cards marriage registration and birth certificates stakeholders have sought reconciliation to overcome the violence and conflicts involving ahmadiyya adherents in manislor and build peace among the communities however to be impactful peace initiatives must be part of a perpetual process that builds supportive social systems this article aims to examine the resurgence of ahmadiyyarelated conflicts in manislor following the progressive postconflict initiatives to seek reconciliation and reduce tensions in the communities many stakeholders including the state apparatuses have taken different approaches to creating peace and harmony within society and preventing conflict escalation the ahmadiyya group consists of 3200 adherents or approximately 70 percent of the total population in the village so peacebuilding needs to consider their unique position as a majority the ahmadiyya adherents have particular ways of contributing to peaceful and productive coexistence this study fills the gap in the literature by providing data on postconflict reconciliation and resolutions initiated by internal and external stakeholders in manislor previous studies have not considered the involvement of local stakeholders in establishing dialogue or how they have systematically initiated postconflict reconciliation therefore this research seeks to discover the dynamics and typologies of postconflict reconciliation the roles of internal and external stakeholders and the process of fulfilling the civil rights of ahmadiyya adherents this study uses a qualitative approach with data collected from fieldwork ethnographic observations interviews documentation and archives the fieldwork was conducted from 2018 to 2020 with multiple visits to manislor to examine the reconciliation process and the fulfillment of the civil rights of the ahmadiyya adherents information was gathered from key informants who could be considered representative of the groups since the technique of identifying key informants is fundamental to ensure a proper representation of a community this study uses the following inclusive criteria 1 prominent figures of ahmadiyya such as preachers and heads of the community 2 the manislors village head 3 officials from the local office of the ministry of religious affairs and 4 religious actors of nahdatul ulama in kuningan this selection process also aimed to ensure a diverse and comprehensive set of perspectives and experiences that reflect the various segments of society several factors were considered in selecting informants to ensure the robustness of data and information they were selected using purposive sampling with deliberation based on the suitability between their experience and the research questions and the characteristics of being a good informant this purposive sampling recruited informants with the expertise and knowledge aligned with the research objectives this approach ensured that the insights gauged could contribute to a more nuanced understanding of the research topic following the rigorous selection of informants the data were collected from observation and documentation for the analysis the collected data were analyzed qualitatively by following maxwells scheme which puts them into three main groups 1 memos 2 categorizing and 3 connecting the findings show that postconflict reconciliation is important various factors have influenced ahmadiyya adherents in manislor to become aware collectively to minimize the conflict and tension and create a solution to maintain harmony and peacebuilding the urgency of reconciliation reconciliation is prevalent among societies with histories of inequity and conflicts and is critical to attaining lasting peace political stability and a just society governed by law reconciliation is difficult to achieve and the idea in a strong sense is utopian but the idealistic applications can be realized by a collective effort of the groups involved in the conflict reconciliation involves transitional justice ie processes and mechanisms to deal with past abuses and histories and achieve accountability justice and peace considering the complex nature of reconciliation neither the process nor the goal becomes the main focus of its definition reconciliation focuses on future aspirations something important to strive for or even an ideal state to hope for that brings sustainable peace to recognize the typologies of postconflict reconciliation this article proposes to understand how reconciliation can reduce to some degree the fatal impacts of a direct and aggressive conflict according to the notion of reconciliation exists in two senses in a weaker sense it is defined as a resignation and in a stronger sense it is a cancellation of enmity or estrangement in this sense reconciliation is done through a morally grounded forgiveness as the conflicting groups acknowledge the collective responsibility for past injustice and overcome their prejudices through a profound and painful identity transformation this second notion seems too idealistic to carry out but local stakeholders are optimistic about bringing peace and bridging a hearttoheart dialogue ahmadiyya is headquartered in london promoting a mission of peaceful sermons with the motto love for all hatred for none it refutes an accusation that it is a political movement aiming to unite all muslims into a nation under a caliphs leadership interestingly the concept of a caliph for the ahmadiyya is a spiritual superstructure attached only to social humanity ahmadiyya adherents in indonesia including in manislor declare that they never question the philosophical theory of indonesia pancasila or the application of other state regulations in indonesia pancasila is not in contestation with ahmadiyyas concept of caliph because the adherents remain national citizens of their respective countries and must comply with the laws as a religious organization ahmadiyya is fully integrated into the adherents social life the ahmadiyya community is the majority in manislor the adherents can resolve tensions and build social cohesion by leveraging social and cultural systems such as the value of kinship in the village other factors have also demanded the community to learn how to observe and adapt to survive as a minority group in the mainstream muslim community they learn to adjust they internally constructed the art of survival to help them deal with social and cultural challenges from the external community they immediately recognized the urgency of reconciliation as a part of the peace process participated in by many stakeholders in the village the participation of local actors in managing and resolving their problems helped the reconciliation process and made it sustainable typologies of reconciliation defusing conflicts and tensions growing religious tensions remain challenges that local stakeholders in manislor have to overcome using different approaches over the years reconciliation efforts have gradually decreased societal tensions and conflicts the success of such peacebuilding can be attributed to internal and external factors the first internal factor is kinship within the manislor community including between the ahmadi and the nonahmadi the second internal factor is the existence of joint social activities which indirectly contribute to social cohesion and positively impact the members such as karang taruna womens organizations sports clubs and so on the third factor is the involvement of elites and religious leaders within the village administration and the governmental structure meanwhile the first external factor is changes and transitions of formal leadership at the regional and local levels which provide room for stakeholder negotiation compromises and leadership transitions were the most noticeable indicators that the reconciliation and peacebuilding process involving the ahmadiyya adherents were achievable the second factor is the involvement and concern of various societal stakeholders such as intellectuals universities ngos elites and national and local figures who educated the public and constructed the publics perspective on ahmadiyya the third factor is the support from the socioreligious groups including nahdlatul ulama the local institute for study and human resource development was initiated by young cadres of nu it has an important role in building harmony and reducing tensions between ahmadiyya adherents and the local government the roles of nu in mediating parties in the manislor community turn tensions into dialogues it has significantly facilitated the peacebuilding process and reconciliation efforts the concept of manhaj in nu focuses on the ukhuwwah islāmiyyah it helps strengthen social cohesion in manislor the understanding is that humanity has the same status as servants of god on earth and that the muslim brotherhood is bound by the same bloodshed and the same nationality and homeland these three values of brotherhood are found in the manhaj aswaja of nu they serve as a logical basis for nus involvement in the ahmadiyya case for various fundamental reasons in dealing with external forces ahmadiyya adherents in manislor used to resist the majority the resistance is not physical or confrontational but rather the struggle of discourse and power involving a knowledge system the power is not centralized but distributed in all directions where reconciliation is needed the strategies ahmadiyya adherents used to resist external forces building a counter narrative and discourse discourse can be utilized as a tool to fight stigma doctrine and in the case of ahmadiyya the insulting opinions of ahmadiyyas belief systems in this case the discourses can be built and strengthened in the ideologicaltheological juridicalpolitical and sociologicalcultural contexts theology in response to the fatwas of the indonesian ulema council kuningan and mui jakarta concerning the heresy in the ahmadiyya doctrines the adherents built a counterdiscourse by producing a narration of true islam it includes several ahmadiyya doctrines delivered in various activities such as recitations sermons and audiovisual media this narration of true islam was based on the recognition of the ahmadis social obligation to spread islamic teachings this obligation is perceived equally important as other obligations such as prayer and tarbiyat ie teaching and educational methods ahmadiyya adherents believe that this is their sacred mission as muslims the sunni muslims are the majority in indonesia strongly influencing the discourses circulating in society the sunni majority dominates the international islamic movement and the narration of culture politics and many other aspects of life this domination intentionally or not invites a contestation in the case of ahmadiyya the adherents are called to express themselves through public and competing discourses for example the mainstream sunni once implemented the 2005 mui fatwa referred to as the majma alfiqh alislām of the oic resolution 4 1985 in the second congress of jeddah the fatwa clearly states that the ahmadiyya are considered apostates and have left islam the ahmadiyya activists countered the attacks against the community with their narrations they consistently produced reproduced and spread their true islamic narrations the summary of the competing narratives is presented in table 1 history the second discourse is in the context of historical narratives the ahmadiyyas resistance was to rectify the misconstruction of their history that their opponents intentionally wrote incorrectly in the constructed history of ahmadiyya mirza ghulam ahmad is a false prophet meanwhile the ahmadiyya adherent genuinely believed that he was the chosen prophet of allah the common narratives spread in society states that the ahmadiyyas shahada is lā ilāha illallāh mirzā ghulām aḥmad nabiyullāh and that hajj is performed in qadianrabwah the ahmadiyya adherents counter these narratives by intensively promoting the narrative that their shahada is lā ilāha illallāh muhammad rasulullah and the hajj is performed in meccamadinah another false claim about ahmadiyyas belief is that paradise can be obtained through paying a certain amount of money it is countered by stressing that heaven is obtained through means of sacrifice politics politics is an arena where the elites and other actors with vested interests capitalize on minority issues to gain power and benefits after the fall of the new order regime minority groups such as the ahmadiyya faced uncertainty more than ever political disputes and actors pressurized the kuningan regencys local government to take immediate action after the joint ministerial decree was issued the local government emerged with a greater structuralpolitical force through the regulations against ahmadiyya which essentially prohibited all forms of activities and ahmadiyya teachings the community was clearly being discriminated against by the state apparatus in this case inequality and conflicts inevitably become the starting point of the healing process the ahmadiyya community produced a counterdiscourse as a form of resistance they refused to recognize the decree because its contents were against the state constitution the counternarrative against the decree and its policy was based on the common roles of the state institutions and the fact that the constitution and international conventions protect freedom of belief the organization was established as a legal entity registered with the ministry of justice as number ja 52313 13031953 in addition the ahmadiyya adherents dedication and loyalty were acknowledged in the struggle for independence of the republic of indonesia the issuance of the decree was resisted by the ahmadiyya adherents by producing a discourse that any laws should aim to protect citizens they insisted that laws must be autonomous and responsive to protect persecuted minority groups and law enforcement must be strict against groups that commit violence social and cultural aspects the ahmadiyya and manislor communities exist as an inseparable unit they take care of each other and have benefitted from each other the village is managed by the local stakeholders mostly ahmadiyya adherents living as a majority in the village they are committed to building the social and cultural aspects and strengthening their social functions as such they organize the social system as well as possible and are always prepared to fulfill social and cultural needs in the best way to avoid tensions related to village management accordingly the manislor village has progressed and achieved several milestones which have also benefitted the ahmadiyya adherents as the local leaders historically a nonahmadiyya candidate never won the elections for the local leadership in manislor at the village level the local political power of the ahmadiyya adherents is strongly supported by various social and cultural aspects to maintain religious solidarity and social cohesion in other words manislor has provided a number of political economic and cultural resources over time developing the arts of defense the arts of defense developed by ahmadiyya adherents comprise three strategies the first is avoidance which is finding ways not to be involved the second is disobedience shown by openly rejecting orders or commands the third is collaboration and fraternizing these are the strategies to challenge the dominating power especially the regulations and rules that infringe on their spaces avoidance strategies are recommended when the ahmadiyya adherents face legal problems and any issues related to official regulations it should be noted that ahmadiyya adherents do not violate the law they obey the substance of the law but they are against the legal structure and its bureaucrats for instance the process of registering marital requirement documents was particularly difficult for them in this case they resist the legal structure by avoiding it and choosing to register at the kua in a neighboring area this shows that they comply with the law by fulfilling the martial documents however they bypass the law that puts them in a disadvantaged position by using alternative ways to achieve the same result in this unfavorable situation the ahmadiyya adherents do not choose to unregister their marriage which is permitted according to islamic law but they are persistent in fighting against the legal structure and operational bureaucrats the ahmadiyya adherents use various strategies to be more actively involved in society since ahmadiyya is a missionary religion approaching with a strategy is key to introducing the organizations value to social circumstances they arrange it through various approaches to maintain social relations such as attending social activities in the area and providing aid to those in need internally ahmadiyya has established social and economic systems through chandah ám economic assistance collected from the adherents assets and incomes they have made this available in the public domain the adherents even go above and beyond in making donations by donating eyes to anyone in need including those outside the ahmadiyya group they also actively organize social activities such as blood donations disaster response free medical treatment and distributing qurban meat │ 107 stakeholders contribution to reconciliation in the peacebuilding process the ahmadiyya adherents engage as many stakeholders as possible to work handinhand and promote the values of living in peace and harmony nu has become the most supportive religious organization that assists in the peacebuilding process in manislor after gaining moral support from the official structure of the organization nus office in kuningan worked handinhand to support the peacebuilding process openly initiated by the internal leaders of the ahmadiyya community the ahmadiyya community has also taken steps to overcome the aftermath of conflicts using social cultural and structural strategies the tension began to subside when various nonstructural circles of government started to pay attention to the issue the ahmadiyya leader in manislor perpetually nurtures relationships with various social and religious groups especially the moderate islamic groups nu plays a dominant role in this context through its stakeholders and nu members in the manislor office this was reflected in the statement by the ahmadiyya leader in manislor we also go to the pesantren and kiai as well such as kiai marjuki in cirebon once he sent a supportive letter to us stating that all muslims must be able to register their marriages nu also supports us not to be afraid this statement was confirmed by the head of manislor village who is also an ahmadi he stated that he built relationships with government institutions and other groups to enhance their reach they also approached nus figures by visiting islamic boarding schools basically whether you like it or not the biggest religious organizations such as nu are still involved everywhere to support the peacebuilding process and reconciliation as such in religious issues the government always consults and asks for advice from nu before making decisions building a good relationship between the local elites and ahmadiyya leaders is a must to solve the complicated situations a commitment like this is welcomed and supported by nu which has proclaimed itself a moderate humanist organization advocating peace and tolerance in line with this as stated by rusli karim there are two social functions of religion the first is as a form of social cohesion that unites individuals and groups experiencing potential conflicts and the second is as a social destruction that forces conflicts of interest between conflicting groups thus far it could be concluded that the nu figures in the kuningan office understood the anxiety of the ahmadiyya figures in manislor people put humanity at the forefront rather than being stuck in the outdated debate of theological interpretation as such the involvement of nu figures in initiating peacebuilding in manislor is a step toward a humanitarian mission the ahmadiyya adherents were viewed as fellow citizens guaranteed by the constitution among the nu figures in kuningan with significant roles z was one of the key persons in the lakpesdam of nu kuningan at that time he was a young figure and an activist who took part in the consolidation in manislor he explained that he initiated a program to promote tolerance in his role in lakpesdam nu kuningan he asked several prominent figures to talk about the cases experienced by the ahmadiyya adherents the findings show that they faced difficulty obtaining identification cards and martial certificates he negotiated with supportive figures inside and outside of nu to resolve the problem and look for a solution the nu office in kuningan held a focus group discussion in collaboration with the manislor village administrators by inviting other community stakeholders such fgd has allowed many sides of the community to hear and share perspectives to find the best way of defusing conflicts and tensions the fgd was also attended by the head of the religious affairs office who stated that the kua was willing to provide the registration of marriage documents of ahmadiyya adherents this collective awareness and understanding were shared among the stakeholders which resulted in good resolutions in tunners language collective existence has become a part of individual subjectivity through a religious ritual in the context of humanity it encourages a person not to be trapped easily in the segregated space between minna and minhum building social harmony social harmony within the community has been established as a negotiation and social commitment for the ahmadiyya adherents toward the outgroup this commitment is informed by empirical findings and influenced by religious teachings meanwhile there are concepts of reconciliation and conflict resolution that were held internally by the community the ahmadiyya community in manislor has passed the reconciliation and conflict resolution phases therefore a followup such as peacebuilding must be conducted locally reconciliation throughout the peacebuilding process targets the ultimate goal of conflict management positive peace following galtungs view the process can create a social system with neither structural nor direct violence in other words the peak of reconciliation and conflict resolution is harmony and building perpetual peace in the context of diversity in the national context the ahmadiyya community is known as a strong supporter of indonesia as a republic and upholds the pancasila national values there has been no historical record of their rebellion against the country the national narrative they built is not much different from the religious concept they believe in the concept of the caliphate in the ahmadiyya belief is none other than a spiritual concept which has no conflict with political practice they have centralized leadership led by a caliph but this leadership is limited in the context of worship this is not much different from the leadership of ṭāriqah in the school of taṣawwuf which sunni groups widely follow the reconciliation process has been fruitful the spirit of building harmony and peace becomes a noble idea and a longterm humanity project the different interpretations of religion are seen as something complementary for the sake of plurality islam has become an inclusive religion for people with moral values influencing life socially politically and culturally in this case tensions should be treated as forms of enrichment upon which peacebuilding can be built │ 109 stakeholders roles in civil right fulfillment the stakeholders roles in resolving the ahmadiyya issues in manislor were significant particularly in controlling and supporting civil rights fulfillment for those who lost their civil rights as citizens such as obtaining an ektp and marriage documents indeed after the severe conflict experienced by the ahmadiyya adherents the religious affairs office did not register the adherents marriages on the grounds of administrative problems the presence of internal and external stakeholders in supporting civil rights fulfillment in a democratic country benefit both the ahmadiyya adherents and the local officers from the perspective of ahmadiyya adherents this support has encouraged them to speak up and show that democracy should advocate and provide freedom of expression and any form of organization the social contract in the establishment of the state is the relationship framework between the state and citizens materialized through the transfer of sovereignty by the people the ahmadiyya adherents stood out to defend their rights by proposing the meaning of freedom in practicing the belief for this reason the state should protect people from threats and intimidation when practicing the belief amid the dispute the ahmadiyya adherents learned from their supporters and advocates to escape conflicts and discrimination meanwhile the local governments actions against the ahmadiyya adherents in manislor can be seen in practice the ahmadiyah adherents try to adjust to societies and their values to coexist they already know when to defend fight break or avoid they often choose an evasive strategy to avoid conflict with the repressive local authorities this strategy also includes resistance and obedience they obey the substance of the law but they oppose the domination of the legal structure by performing nikah numpang the same is true for the ktp issue the way ahmadiyya adherents are resilient in implementing the strategies encourages collective awareness for example the ahmadiyya elites held an fgd in collaboration with lakpesdam of nu in kuningan the fgd was attended by various groups agencies institutions and community representatives and produced important recommendations such as the fulfillment of the right to register marriages at kua and an ektp in practice implementation of the recommendations is not straightforward and requires a long and gradual process after the consolidations by stakeholders and the ahmadiyya adherents tensions have started to subside the civil rights which the adherents were mostly worried about could soon be realized in dealing with this context the critical successful factors learned from the ahmadiyya adherents experiences in manislor could be categorized into three the first is about the collective psychopolitical consciousness of ahmadiyya itself which has grown massively and impacts the reconciliation process the shared experience includes facing the same struggle and suffering it creates a collective consciousness the second factor is good communication skills by ahmadiyya leaders and elites to build relationships and networks which become resources for reconciliation the third is the involvement of several civil society groups consisting of socioreligious organizations such as nu religious social figures and activists nongovernmental stakeholders research institutes educational institutions and several other institutions that assist ahmadiyya in obtaining their rights as legal citizens of indonesia conclusion the experiences of massive conflict violence and discrimination endured by the ahmadiyya adherents have taught them to formulate a strategy such as by inviting agencies and stakeholders to support them this article has revealed the typologies of postconflict reconciliation 1 the production of a counter narration to address any information that discredits the ahmadiyya adherents 2 the participation of active and supportive stakeholders to promote a peaceful life in the village and 3 the fulfillment of civil rights of ahmadiyya adherents these findings conclude the reconciliation steps taken by multiple parties both informally and formally are needed for communities to live in harmony and peacefully with mutual respect however achieving equal rights as legal citizens has certainly not been easy a long process of reconciliation sacrifice and optimism has reduced tensions caused by the conflict postconflict life through building mutual peace as in manislor is a longterm project the involvement of civil society socioreligious organizations acting as mediators academics and campuses national elites and local figures is needed to restore peace

religious conflicts pose a threat to social integration including those involving the ahmadiyya muslim community in indonesia this article discusses the postconflict reconciliation and fulfillment of civil rights among ahmadiyya adherents in manislor kuningan west java indonesia social actors have a powerful position in the reconciliation and fulfillment of civil rights which have become one of their most apparent violations against ahmadiyya adherents in manislor this study uses a qualitative approach with data collected through fieldwork and ethnographic observations with ahmadiyya adherents in manislor this article scrutinizes 1 the typologies of postconflict reconciliation 2 reconciliation efforts in the communities by leveraging cultural and religious aspects and 3 the struggles of fulfilling civil rights such as issuing marriage certificates and identification cards the results show that the willingness of ahmadiyya elites to meet with stakeholders and socioreligious organizations particularly in kuningan regency created a space for a dialogue of understanding that helped the reconciliation between ahmadiyya and the wider community in manislor this study contributes to clarifying the pattern of reconciliation based on the local approaches durably practiced by ahmadiyya adherents in manislor kuningan west java konflik agama yang terjadi di masyarakat mempunyai efek laten yang seringkali menghambat proses integrasi sosial termasuk dalam kasus ahmadiyah artikel ini membahas tentang proses rekonsiliasi khususnya pemenuhan hakhak sipil pasca konflik dan perselisihan sengit yang terjadi di kalangan penganut ahmadiyah di manislor kuningan jawa barat indonesia posisi para aktor sosial telah terungkap sebagai dampak yang kuat dalam rekonsiliasi untuk menjelaskan tentang realisasi hakhak sipil yang telah menjadi salah satu fakta paling buruk terhadap penganut ahmadiyah di manislor penelitian ini menggunakan pendekatan kualitatif dengan melakukan kerja lapangan dan tinggal bersama penganut ahmadiyah di manislor untuk melakukan observasi wawancara dan dokumentasi artikel ini mengkaji 1 tipologi rekonsiliasi pasca konflik 2 upaya rekonsiliasi yang dilakukan dalam konteks komunal dengan memanfaatkan aspek budaya dan agama dan 3 naik turunnya pemenuhan sejarah hakhak sipil untuk memfasilitasi hakhak masyarakat melalui penggunaan akta nikah dan kartu tanda penduduk hasil penelitian ini menunjukkan bahwa kesediaan elite ahmadiyah untuk bertemu dengan pemangku kepentingan dan organisasi sosial keagamaan khususnya di kabupaten kuningan menciptakan ruang dialog pemahaman yang membantu rekonsiliasi antara ahmadiyah dengan masyarakat luas di manislor penelitian ini berkontribusi untuk memperjelas pola rekonsiliasi berdasarkan pendekatan lokal yang selama ini dilakukan oleh jemaah ahmadiyah di manislor

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introduction urbanity the catchword of contemporary town planning remains underdefined in the parlance of practitioners this is also the case in the finnish capital with its powerful planning institution illustrating my theoretical treatment the conceptual vagueness is reflected in the results of urban design affecting the urban experience and urban life sociologists studying town planning again sometimes find architects strivings naïve from the social viewpoint however the former tend to avoid dealing with specific design traits and thus entering the latters professional field while social scientists scarcely reject the idea that architectural properties somehow affect liveability and social interaction many still seem sceptical of social design knowledge such as that of jane jacobs treat the design issue abstractly or limit themselves to citing the divergent standpoints of actors involved in planning conflicts consequently in finland at any rate there is little detailed professional or academic reflection on architectural urbanity11 as such and on its relation to urbanity in the social sense to address these issues i shall try to clear up the conceptual problem and suggest an understanding congruent with classics such as jacobs that simultaneously guides architecturally focused town planning what everyone appears to agree on is that diversity is pertinent to urbanity together with some other generally acknowledged but often unspecified physicalfunctional traits it supports a notion of architectural urbanity going beyond the rudimentary idea of mere concentration and some synergic efficiency however it is not evident what kind of diversity is relevant and how the desired property differs from chaos or unwanted forms of it in basic respects abstractly understood or within a given theoretical framework diversity and the other characteristics such as concentration efficiency synergy and intensity are internally related to urbanity as their interconnection may be ascertained by logical or definitional clarification concerning how the terms are or should be used rather than requiring empirical investigation therefore rushing to measurement or to suggesting new forms of urbanity adaped to contemporary conditions without satisfactorily treating the conceptual question might further obscure the idea nevertheless the above features are undoubtedly part of an elementary comprehension of urbanity which partially rests on everyday language and culturally contextual meanings this conception as well as more scientific ones have been influenced by ecology12 a prominent ecological analogy is that of transitional zones rich in biodiversity such as the common edge of a wood and a field other biological analogies serving architecture urban design and town planning in this finnish or scandinavian context i shall not treat these spheres as clearly separate is the permeability of buildings or perimeter blocks comparable with the properties of cell membranes today at the same time as a certain scientism lingers on in social science and urban design theory natural scientific influences on social science such as social darwinism13 have become the target peerreviewed article toni kotnik of standard criticism nevertheless such analogies form the basis of all thinking scientific conceptualisation included it is therefore critical to identify the limits of them rather than trying to purify science of everything except unambiguous terms and hypotheses serving as the foundation of selfsufficient internally consistent theoretical systems dependence on common sense and metaphors become problematic only when differing interpretations impede clear theoretical treatment or rational action for example interested parties or external observers might not grasp what ends town planners are aiming at in referring to urbanity when narrowing down the meanings the architectural and social sense of urbanity and diversity must be distinguished as much confusion has resulted from not keeping them separate to attain that purpose the four notions following from the distinction architectural diversity architectural urbanity social diversity and social urbanity must be analytically separated precisely to allow for an investigation into the ways they are interrelated within social science the architectural aspect of urbanity is sometimes treated as an empirically or conceptually insignificant surface manifestation of a phenomenon that only the social aspect of the notion may properly capture while social scientists might criticise the vague meaning of the notion or failures to realise its complexity 14 empirical even quantitative studies are carried out within the field of urban design to enhance our understanding of the phenomenon the present elucidation of architectural urbanity is mainly descriptive to begin with although the effort of determining idealtypical urban traits contains a judgemental element of a formally normative nature in practice the description should be commonly acceptable nonetheless in line with its guiding purpose the account turns more decisively normative once town planners themselves are aiming at distinct architectural urbanity to stand a chance of producing substantial consensus the treatment needs to keep to the core of the explored notions this i hope might contribute to making academic discussions less obscure in addition the clarification should in principle help town planners approach their ideal to be sure these theoretical pretentions do not imply that conceptual confusion is the only obstacle to reaching true urbanity the starting point of the present argumentation analysis conceptual analysis and conceptual development is thus the articulation of an architectural notion of the urban this involves a basic or prototypical urban structure which will be related to jane jacobss and other classics account of a wellworking urban environment the characterisations are compared with some contemporary treatment of urbanity and diversity without needlessly interfering with artistic freedom the descriptivenormative view argued for complements the current technicaljuridicaleconomic boundary conditions for urban design with those set by social design knowledge prototypical architectural urbanity and diversity to prevent common confusion relating to its meaning architectural urbanity will here be given an intuitive minimal if strict interpretation involving prototypical traits of the traditional european city these properties are intended to translate into default norms for contemporary city building with a pronounced urban intent the conceptualisation is meant to be trivial rather than idiosyncratic yet useful in making some fundamental principles of traditional urbanity explicit as such it 14 extreme examples are thomas wüst regarding urbanity as a myth and loretta lees denying its definability as it is always in the process of becoming a moderate critic klaus selle finds the meaning of the notion lying somewhere in between the hopelessly ambiguous and solemnly imprecise within social science the architectural aspect of urbanity is sometimes treated as an empirically or conceptually insignificant surface manifestation of a phenomenon that only the social aspect of the notion may properly capture peerreviewed article toni kotnik reveals frequent breaches against them in contemporary town planning which occur even when marked urbanity is the declared aim the account is minimal first in being purged as far as appropriate of social content even though all traits emphasised have social implications the description is aimed at capturing fundamental urban forms from an architectural viewpoint second it excludes any obviously controversial elements of an architectural or urban design kind the expectation is therefore that some might find the conceptualisation incomplete while few should regard any of the conceptual components redundant for the architectural dimension the most important characteristic of the architecturally urban is the socially significant public street space usually defined by buildings delineating it reflecting this the perimeter block becomes another basic building block of the traditional city in various places the street space is intensified or attenuated depending on dimensions functions and location into a square instead of perimeter blocks of course there may be larger squares or parks public space is supported by buildings and particularly ground floors that typically communicate with the street functionally and visually at least along main routes the function is realised by corner shops other businesses and public services a further feature is that the urban spaces for the most part are of moderate or specifying the degree or kind of urbanity intimate scale equally plots are usually of moderate or small scale implying several buildings in each urban block 15 likewise façades are detailed reducing mental distances 16 lastly some properties of the urban space to the same effect such as curved streets or alternatively in a grid structure architectural backdrops of streets also diminishing psychological distances might be added yet they may rather be part of a more elaborate and contestable programmatic understanding this characterisation of architectural urbanity includes several traits furthering social diversity thus the street space enclosed by the perimeter block collects people into a theatre of public life the perimeter block potentially articulates different kinds of spaces the public space of the street square and park and the semipublic or semiprivate space of the enclosed courtyard enabling different kinds of activities small building units and ground floor premises again as well as the scarce dimensioning of streets and squares allow for proximity thereby diverse activities and people are brought into actual contact with each other furthering interaction rather than diversity just being present in principle as an unrealised potential this might happen in suburban conditions even when enterprises within business parks commersial centres and housing are situated relatively close to each other 15 architectural critic mikael askergren agrees with those denying the existence of a commonly accepted concept of urbanity making it useless for science responding to this he singles out the above specific dimension of urbanity as a sufficient determinant of the notion operationalised by his u number defined by the relation between the length of the internal plot boundaries within an urban block and that of the outer plot boundaries defined by the street 16 the qualifiers relating to dimensioning may be specified by typical metrical widths of central streets and measures of building units in different contexts of traditional urbanity more important than the exact measures is the contrast to modernist design solutions shattering the human proportions of streets and buildings peerreviewed article toni kotnik so far constraints on architectural diversity have been suggested to ensure traditional urbanity simultaneously the constraining principles generate architectural diversity in requiring small units and detailing of buildings on the macro plane more radical architectural diversity might still be achieved by allowing for modernist freestanding towers and large open spaces such new urbanity has indeed been realised in the significant development area and traffic junction of pasila in helsinki the location of this second centre might be assumed to support such experimentation if being developed as part of the fringearea of the inner city yet the reasons stated for such urbanity by the italian architect cino zucchi in outlining an earlier version of the project are noteworthy17 according to him the impossibility today of creating urban gems such as the esplanade in the finnish capital forces us to invent the city anew no account of why the traditional ideal cannot be achieved or for the reasons for jumping to its opposite heavily criticised by jacobs jan gehl and others have been given by zucchi or the project managers another example of untraditional architectural diversity on the level of the urban structure closer to the oldstyle city are the brokenup îlots ouverts in quartier masséna in paris by christian de portzamparc each urban block of the area is characterised by several freestanding buildings with variousy active ground floors separated by narrow spaces courtyards visible to the street might be assumed to contribute to their social or even biological diversity but are not consistently designed for such uses some planning academics however have welcomed his design principles in the name of diversity and as an alternative to the dichotomy between traditional and modernist urban structure the project is also relevant for evaluating current town planning in helsinki as the citys new innercity districts on former harbour areas partly approach his idea with their brokenup quasiperimeter blocks what benefits might the deconstruction of the perimeter block bring for urban diversity portzamparcs solution partly conforms with but does not add to the prototypical urban structure by including several buildings in each urban block rather than only one or two extensive ones as is often the case in the new developments in helsinki it does intensify the dynamics of the urban landscape by disclosing architectural background layers and visual foci on the street level through the gaps between the buildings while the solution also opens up more views from flats and might increase their access to sunlight removing building masses from the street line to the courtyard lessens this quality outdoors as compared with the perimeter block without backyard buildings further gaps along the street weaken the territorial sense and in central locations spreads noise to flats and courtyards lastly a prototypical urban structure might be an ample resource in both central helsinki and paris intramuros 18 nevertheless so is suburbia in addition most town planners of central helsinki perceive themselves as enlarging the real inner city zucchis and portzamparcs solutions might diversify cities on the macro level in an architectural sense and preserve here largely irrelevant functionalist virtues such as abundant sunlight nevertheless to be urban in a strict sense architectural diversity depends just as social diversity does on a consistent pattern of a few building peerreviewed article toni kotnik blocks to increase architectural diversity at street level within its limits one may decrease the lengths of buildings along streets let different architects design neighbouring buildings vary building materials colours et cetera at least some of these measures simultaneously increase social diversity and urbanity for instance small units make for numerous small businesses on the ground floor at the macro level one may vary organic grid and nodebased urban structures noone would prefer classical corridor streets such as the boulevard in helsinki to be broken up by more empty spaces between the buildings jacobsian urban diversity the principle of limiting architectural variation to a stable combination of the most efficient key elements for effecting a high degree of social diversity most obviously characterises the thinking of jane jacobs part of her minimalism is to regard the grid as a fully satisfactory form of the urban macro structure nonetheless it should be noted that there is some intricacy in other basic elements she suggests as each is to secure various uses by offering different kinds of places in the vicinity the physicalfunctional traits she singles out are those playing an obvious social and economic role this priority differs from that of the above account indirect from the social viewpoint focusing on properties that primarily make up a traditional architectural setting for urban life whereas the idea of a prototypical urban structure is essentially compatible with jacobss principles portzamparcs alternative partly departs from them while zucchis defines their opposite for jacobs urban diversity essentially consists of or depending on the viewpoint is produced by mixtures of uses instead of therefore starting out by asking what traits are most characteristic of traditional built urban environments she immediately focuses on what traits in the built urban environment correlate with and by some easily grasped mechanism produce diversity the property depends on four preconditions or generators first the general condition of mixes or combinations is specified by requiring neighbourhoods to have more than one primary use a plurality of primary uses in its turn brings about more diverse secondary activities serving the primary ones streets are thereby kept active at different hours second urban blocks should be short securing alternative pedestrian routes and better accessibility to services again allowing for alternatives as well as for specialisation this trait is architectural in an elementary sense but does not characterise all parts of the traditional european city third buildings of different ages and conditions are needed to ensure among other things that different kinds of corner shops may afford the rents fourth the population must be concentrated to achieve a high enough density jacobs restricts the validity of her findings to the central parts of big cities if one nonetheless considers applying the results elsewhere it should be noted that she only studies american conditions and that she wrote her magnum opus more than half a century ago the world might therefore have changed in significant respects nevertheless one should not by interpreting the contextdependence of social science too strictly reject a generalisation of her penetrating and systematic mapping of conditions for urban diversity unless it is made clear how the provisos indeed invalidate its application in a certain case thus there is no definite reason why the four principal rules would not apply to small european towns 19 still all principles need some critical attention before being implemented peerreviewed article toni kotnik the first principle recommending mixed uses is certainly difficult to modify without abandoning the essentials of jacobss thinking one might ask whether the specification of the rule as more than one primary use of a neighbourhood makes its application to some parts of the city impossible even central ones where some function typically housing clearly dominates yet an incontestable definition of what amounts to a primary use is hardly called for here the main point is to avoid a functionalistic separation of activities the second principle that of short urban blocks might be more dependent on big city conditions jacobss point of long street sections being wasteful of resources and frustrating for users may be valid given that there are people enough to support the spreading of services to different streets at this point jan gehl appears to argue for the opposite position as he emphasises the need of collecting the flows of people for supporting diverse services and supplementary activities however what he criticises is the typical suburban structure with buildings in a park where each can choose his or her own path and people never meet to support other than primary or necessary activities even when the population within the area is relatively dense in other words the urban block structure as well as dimensioning and quantification are critical here the third principle according to which there must be both new and old buildings and thereby premises in different states of repair is less dependent on the size of a city although unaffordable rents is typically a bigcity problem more relevant are the general socioeconomic conditions the requirement of historical variation of course makes it hopeless to urbanise new districts without improbable regulations reserving some plots for future development societal circumstances again are critical for whether the link between the age of a building and the level of the rent necessarily holds in the first place in a welfare state like finland where the state and municipalities regulate markets uses may be subsidised depending on the form of tenure thus one may ask whether this condition is necessary for urban diversity or might rather be regarded as a factor supporting the liveliness of street life 20 a more general question to be posed is how jacobss laissezfaire economy in fact works on street level given realworld capitalism it can hardly be denied that economic processes need an infrastructure of rules partly achieved by planning the fourth principle presupposing sufficient density might in view of the context appear to imply big city standards but need not the rule of concentration is applicable almost anywhere even if at some point principles for achieving jacobsian urbanity become futile and questionable although abstractly enough interpreted one might learn something from her even in respect of our villages with a church or smaller population centres other principles for creating a socially wellworking built environment besides those relating to urbanity and urban diversity should not be forgotten to recognise the real variation one may work with axes from the urban prototype to the rural and the suburban respectively while trying to find local optima on the way 21 20 contemporary sociological accounts of urbanity tend to regard historical layers as necessary for other reasons as well typically for an urban atmosphere to be realised at the cost of design traits as such 21 san vittorino romano and telč as towns that are squares might be perfect small towns for uncompromising urbanists such exemplars are indeed interesting and might be socially wellworking nevertheless taken as an ideal to be emulated the solution might unjustifiably restrict diversity without living up to jacobss urbanity clearcut models may enhance understanding and when appropriate for reaching common goals shift the burden of proof to those against implementing them yet realworld planning must also respond to local tradition and exigences peerreviewed article toni kotnik the goal of jacobss urban design recommendations in any case is the production of urban diversity and thereby lively streets again being socially beneficial in various ways the principles themselves are partly simple partly intricate nonetheless the rules are strict even if their abstractness allows for various realisations there are still clear limits to architectural diversity following exactly from the requirement of securing social diversity within aesthetically focused and pragmatic architecture the pressure towards originality which an artwork is conceived to depend on for its value sometimes make practitioners reluctant to heed such restrictions in addition to more strongly sanctioned ones the latter are typically of a technical juridical economic or political character there is also the tension rather than opposition between decidedly urban and prevailing modernist principles as the latter tend to focus on what is perceived as the aesthetically and functionally essential refraining from extras such as ornaments there is a risk of throwing the baby out with the bathwater if not special care is taken in the detailing of buildings and urban environments as far as such environmental properties have real effects on urban life it appears sociologically important to explorie knowledge and power related to their realisation this presupposes that the knowledge and the issue itself are recognised as irreducible to politics layers adding to the jacobsian urban structure the jacobsian principles are neither architectural in any demanding sense nor aesthetically centred the virtue of jacobss teachings lies in their relative simplicity emphasising consistent application of straightforward rules to produce urban diversity nevertheless to make space for ideas introduced by other writers more architectural ones included and accommodate her views to european exemplars of urbanity such as that of helsinki prague or paris one may regard jacobss recipe for pronounced urbanity as a base on top of which variation that does not interfere with the spirit of her work may be added also one may suggest attenuating her principles stepwise in a conceptually disciplined manner without abandoning the core ideas to derive principles for developing less central areas and to allow for public buildings and other exceptions to the prototypical urban structure the critical question is what modifications the rules permit and insofar as they forbid indisputably urban traits how they may need to be revised a feature characterising the exemplar cities is their partial deviation from the urban grid the nongrid structure supports the generally expected formindependent variation in the intensity of urban life concentrating it at nodes this again brings the variation in the publicness of urban spaces to the fore and thereby the problem of how to treat less central streets and spaces with high enough densities no street will be left deserted despite the gradient created between nodes and peripheral areas this applies for instance to an haussmannian urban structure characterised by focal points such as notably the place de letoile in paris even so efforts to secure activity along peripheral street sections may be advisable implying a diversification of the elements generating urban life for instance in quiet streets where residents will not be disturbed by traffic noise and passersby suitably dimensioned forecourts may ensure the communicability of ground floors towards the street except for peerreviewed article toni kotnik working as transitional zones between the privateness of the home and the publicness of the street forecourts perceived as antiurban by somecontribute to diversity in activities and lifestyles by offering small semiprivate outdoor spaces and the possibility of gardening in the city one may here refer to other classics whereas jacobs bases her views on systematic observation and commonsense identification of mechanisms christopher alexander et al seamlessly ground their theory formulated in a pattern language on the philosophical worldview formulated in a timeless way of building and often base their specific recommendations not only on their professional experiences as architects but also on scientific findings instead of presenting a limited number of necessary measures securing wellworking urban diversity they offer a graded set of rules pertaining to different levels of design 22 a crucial way in which their work challenges or complements that of jacobs is in emphasising the importance of creating different levels of urban vitality for different needs and groups of people the categories of kevin lynch such as nodes and borders define an opposite to jacobss indefinitely continuing grid his focus is on orientability and sensemaking rather than on social diversity the urban hierarchies required still entail diversity of different kinds jacobs secures the coherence of the city mechanically for example in prohibiting gaps between buildings in contrast lynch guides the designer along different dimensions 23 nonetheless there is a need to keep to jacobs closely enough for prototypical urbanity not to be lost when other ideas are introduced the real problem however is not competing theories but analytical unjustified schemes appearing within urban design when architectural trends are followed without theoretical reflection town planning might run counter to principles of urban coherence not only programmatically or by overemphasising aesthetic trends but by simply abandoning the urban design level of architectural thinking when a coherent urban design grammar is dropped whatever its nature diversity turns into senseless chaos not the least in finland the phenomenon involves a diluted corbusian ideology which in breaking up the urban structure has secured views and above all cheap parking spaces the consequences have been accumulating in the central grid areas of the finnish cities and towns except for that of the capital at least since the 1960s 22 this seems a promising way of addressing the question whether design rules should be binding or work as inspiration while their theoretical basis hardly stands a philosophical analysis this does not necessarily invalidate their findings due to the underdetermination of facts by theories which implies that there may be different theories explaining independently established facts this is so both on the level of explaining peoples behaviour in public places and that of grounding a theory yet some of the alleged scientific facts impeccably cited in their work are startling enough to necessitate a critical review of the sources this most obviously pertains to the rule belonging to their most trusted category forbidding buildings that exceed four stories as inhabitants are otherwise supposedly driven crazy 23 stephen marshall misinterprets the metatheoretical status of lynchs thinking and therefore requires his abstract comprehensive categories to be empirically grounded repudiating such a view complementary elements may instead be added in his spirit one possibility are city gates where routes meet borders as may be observed along the approach roads of helsinki peerreviewed article toni kotnik there are examples of deficient adherence to wellknown principles of urbanity even in the finnish capital which is planned in an architecturally disciplined if not always theoretically rationalised way examples of occasional breaches against notably jacobss rules in the innercity extensions into former harbour areas are lacking corner shops insufficiently communicating ground floors plots and buildings taking up half an urban block as well as frequent ungrounded openings towards the courtyards destroying the perimeterblock structure the gaps perhaps less obviously problematic than the other deficiencies weaken the urban feel sought for as well as the articulation of the difference between semipublicsemiprivate and public space this is particularly disturbing when technical considerations defeat aesthetic ones returning to some difficulties in jacobs justifying a partial deviation from her rules some urban diversity is simply forbidden by her such is perhaps most obviously the case for that created by semipublic or semiprivate courtyards contrasting with the public life of the street in allowing for activities different from those of the street courtyards potentially promote social diversity for jacobs however such competing spheres detract from the public street life characteristic of big city life as distinct from the privatised life among acquaintances in suburbs or smalltown communities another reason for departing from the jacobsian principles is the need to accommodate structures larger than normal urban blocks for there to be diversity its opposite must be present there must be comparatively homogeneous components making it up families businesses schools and hospitals need to carry out their activities and develop their cultures in relative isolation 24 although jacobs recommends premises and buildings of varying size to increase the diversity of possible functions this variation is to be kept within limits not to act contrary to her rules she therefore finds bulky monofunctional elements such as university campuses breaking up the normal socially diverse urban structure problematic jacobss brutally straightforward view on causal mechanisms might partly depend on an american logic logic rather than for instance scandinavian conditions the lack of diversity causes the interest in the area among potential passersby to diminish entailing less people therefore less eyes watching the area the vicious circle eventually producing damage criminality and slum nevertheless structures not easily integrated into jacobss normal grid might still add to urban diversity including social diversity on the macro level if one therefore goes beyond jacobs it should be considered how an efficient interface and communicating elements 25 between the foreign body with its semipermeable boundaries and the rest of the city may be secured attention should also be paid to how the exceedingly large structure itself even if only semipublic might emulate the beneficial properties of the prototypical urban structure or of some of its elements such as a park the physicalfunctional organisation of the establishment must then find a balance between its component groups specialising in isolation and their sharing of ideas at hierarchically ordered meeting points peerreviewed article toni kotnik there are thus some difficulties with strictly following the concise and instructive jacobsian rules already in the context of the central parts of big cities as the grid in principle generates an endless undifferentiated urban structure neither do the rules allow for desirable variation on the privatepublic axis in addition wholeheartedly embracing jacobss message might be problematic for a sensitive appreciation of urban values outside the central streets and parts of big cities jacobs herself allows for diversity on this count in stating that there is nothing wrong with suburbs and small towns for people appreciating their calmness who lack ambitions et cetera … yet to achieve some desirable urban traits may depend on partially implementing jacobss thinking even there to avoid some of these problems one might regard the urban environment produced by jacobss key principles as a kind of prototypical urban structure on top of which architectural and aesthetic elements not critically conflicting with her stated conditions may be added however for slightly less urban but still urban areas to be recognised and developed there is also a need conceptually and practically to deconstruct big city urbanity in a controlled stepwise fashion this presupposes a prioritisation of principles in addition it requires a relatively strict definition of hierarchical types of builtup environments according to which various traits of the prototypically urban may be dropped or attenuated such zones are readily identifiable in our cities and towns new urbanist transect principle is an exemplar of such a conception its function is precisely to define degrees of urbanity from the central business district through the suburbs to the countryside specifying architectural traits appropriate for each environment however to be commonly acceptable even for finnish modernist architects the basic idea must not be interpreted as depending on the specific instructions of the rather detailed new urbanist design rules architectural and social urbanity and diversity anthony giddens has pointed out that the city has lost its peculiar and allimportant role after the middle ages when the city wall encircled a world wholly different from the surrounding countryside the wall thereby carried much more weight than its physical mass preserved walls have lost their power to protect a divergent juridical and cultural order inside nevertheless for the present treatment it matters that they still delimit an area that not only offers reminiscences of times passed and an intense urban feel but enbles distinctive behaviours and economic activiy inside this is not only for touristic reasons but due to the areas intense architectural diversity and urbanity achieved by dimensioning and architectural detailing bringing different activities and people closely together in a context of a vibrant urban athmosphere provided certain minimal conditions the design would work even if the old town were a reconstruction or a new development with such architectural traits when part of a larger city the old town thus offers diversity on the city level as well since the symbolic breakdown of the medieval city walls urban culture has spread all over giddenss argument referring to marx with the quote modern history … is the urbanisation of the countryside might be regarded as a generalisation of the point made by pasi mäenpää that suburban and even rural finns are in fact urban in a cultural sense however much the thinness of our urban heritage is emphasised in some circles nevertheless even if there is no absolute demarcation line between the urban and the rural in contemporary society one can hardly deny the existence of cultural differences between on the one hand rural and small town life where everybody knows everybody and on the other to a large extent anonymous big city life just as jacobss depiction of small town life may be biased there always remain cases disconfirming any supposed invariances relating the size of a place to behaviour still cultural differences are real for those illadapted to the peerreviewed article toni kotnik occasional narrowmindedness of tightlyknit groups the ageold saying stadtluft macht frei might not be wholly obsolete what again counts in the present context however is whether architectural traits contribute to cultural differences spontaneously developing between large and small culturally cosmopolitan and locally attached communities obviously some minimally architectural conditions define the urban in the first place also the urban structure constitutes the setting for urban life presupposed by the sociological classics treating urbanity doubtless for georg simmel and others the intense diversity described took place in an environment of a prototypically urban architectural kind a difficulty with diversity as a conceptual and programmatic foundation for urbanity is its dependence on an implicit commonsensical normative understanding for example segregation or functionalistic town planning is criticised for decreasing diversity however in a literal sense nogo areas gated communities or noxious industries within housing areas increase diversity on the macro level not all phenomena logically implying diversity will therefore be accepted by language users as part of what is in fact intended by the word also certain kinds of diversity will restrict other kinds of diversity as the pasila and quartier masséna examples intended to show admittedly common use of language has established typical meanings enabling normal political and scientific discourse yet especially within the pragmatic and conflictridden field of architecture urban design and town planning trusting intuitive intentions does not necessarily suffice to clarify issues or solve problems this defines a real difficulty when social scientific treatment of urban problems starts out from an everyday understanding of socially significant urbandesign properties sometimes such a point of departure is tied to certain misgivings about planning exactly this problem appears in some of the contributions to a collection treating new forms of urbanity in europe and the usa for example rolf lindner comparing new developments such as hamburgs hafen city with traditional environments writes with regard to diversity each city must distinguish itself in terms of culture lifestyle and milieus t his achievement is not something one can plan realising that any intentional action or goal achievement nonetheless presupposes planning in some sense lindner continues by instead suggesting a policy of diversity which should create and preserve an environment which is necessary in order for diversity to be able to prosper however the measures he suggests such as antidiscriminatory ones are of a social kind he concludes that there cannot be any magic formula for the future design of cities while the word magic forestalls criticism according to the present interpretation architectural urbanity whether selfgenerated or achieved by meticulous planning might form the needed foundation for social difference and diversity to thrive according to lindner however perfect planning of a kind he finds in the hafen city of hamburg produces monocultural diversity the idea is certainly worth exploring26 yet when he continues by asking in a place where nothing is left to chance is there any hope for chance meetings and chance peerreviewed article toni kotnik discoveries at all one might suspect some rhetoric obscuring the substance of the matter if buildings and roads are laid out in a random fashion random meetings are less likely than when carefully designed to concentrate flows of people backstages and secret places called for by lindner definitely belong to such an environment if as he claims they are missing in hafen city its planners after all have not thought of everything under the following subheadings i shall sum up some key issues relating to architectural and social diversity and urbanity there are often values competing with them and syntheses for instance except for architectural diversity harmony is needed the same goes for even more politically laden social objectives what kind of architectural and social diversity is desirable is ultimately a political question however one should not hurry to that conclusion but consider how urban design knowledge might contribute to making an informed choice given shared general values architectural diversity architectural diversity on the street level emphasised by jacobs is to be prioritised as it affects the urban experience more tangibly than diversity on the macro level there are two potentially contradictory kinds of architectural diversity the first is achieved by strict rules for the urban structure securing small enough building units preferably designed by different architects the second results from breaking or varying the rules governing the first kind of architectural diversity such breaches may be unjustified even when outspoken urbanity is not the goal this applies to situations where architectural diversity is attained at the cost of a socially wellworking environment on the other hand varying the rules may be justified even when consistent urbanity is aimed at for example a relaxed version of the prototypical urban structure allows for exceptions increasing architectural diversity on the urban block level such as freestanding public buildings analogues of transect principles again might graduate the level of urbanity in a controlled way architectural urbanity there are different degrees of architectural urbanity as well as sophistication in its understanding as to the first there is an axis from central big city urbanity to small town urbanity suburbanity or rurality a shared commonsensical conception of urbanity accentuates concentration efficient landuse and perhaps some synergy between functions and even diversity nonetheless a popular grasp might lead us astray in for example focusing on massiveness and highrise building which makes up a mechanical or even primitive concept of urbanity at least as problematic however is not to distinguish the architectural dimension of urbanity and as a consequence to introduce sociological criteria at the cost of attention to architectural traits affecting urban life although diversity is a key concept integrally involved in urbanity it is as important to generate synergy and intensity in the interaction between diverse elements enclosed and appropriately dimensioned public spaces are significant in this respect dynamism achieved by juxtaposing elements of contrasting character and size as well as by emphasising movement is a further possible element in urbanity however all characterisations of architectural urbanity do not present necessary conditions the role of the notion of a basic or prototypical urban structure is thus to point out some essential elements social diversity in my treatment the assumption has been that architectural diversity consistent with prototypical urbanity unproblematically supports social diversity still not any social diversity is desirable for example some kinds of impressive big city social peerreviewed article toni kotnik diversity might presuppose huge differences in wealth typical finnish urban environments on the other hand providing for standard needs for everybody might be tedious in their homogeneity in social terms a balance must be struck between diversity enabling various lifestyles and and social diversity presupposing material and cultural inequalities the results of both reflected in architecture in any case one may hold that human life as such generates diversity that architectural solutions should enable to flourish given a sound geographically possibilistic or structurationist background understanding the issue of environmental determinism hardly arises social urbanity in my treatment the nature of social urbanity has largely remained implicit and unexplained a proper elucidation of it would have turned the focus from the main issue sociologists emphasising the spread of urban culture to the point of emptying the notion of a clear content are probably right again the concept should be clarified and preferably in a way that does not alienate it from the architectural viewpoint the existence of mechanisms producing divergent social life in big cities and small villages is an almost trivial fact the issue is in what ways architectural traits are truly involved in the present discussion not completely ortodox in relation to jacobs much of the architectural diversity supporting social urbanity might catalyse small town characteristics such as neighbourhood gemeinschaft developing in courtyards and along forecourts nonetheless the prototypical urban structure is meant to serve as an idealtypical background for an understanding of the social life and possibilities that a traditional city supports concluding discussion my treatment has aimed at an identification of design principles securing architectural urbanity in its turn creating preconditions for social diversity and thus for urbanity in a social sense as to diversity it is critical to be clear on its kind level and content since the unspecified word is highly ambiguous while architectural diversity to further social diversity must be strictly conditioned jacobss principles might be liberalised to allow for differentiation of different levels of publicness as recommended by alexander et al lynchs basic categories help grasp and organise variation at the macro level as does the transect principle of new urbanism here as elsewhere it is important not to mix abstract ideas and rules with their specific architectural realisation equally critical though is to understand the real constraints that fundamental rules such as jacobss impose once accepted however one might ask to what extent each of jacobss key principles are necessary or sufficient for achieving urban diversity or just contribute to it there is also the procedural issue of whether or to what extent planning is needed to realise the urban design principles promoting the objectives a presupposition for the treatment has been not only that some planning is necessary but that strict comprehensive town planning might further the aims of architectural urbanity better than anonymous capitalistic processes giving rise to a spontaneous order the same might be said in relation to political procedures however democratic if not all aspects of the knowledge base of urban design are taken seriously urbanity in its different guises connects to wideranging societal concerns such as the democratic formation of public opinion in a pluralistic society theoretically it is tied to the general issue of how spatial properties and artefacts with spatial and symbolic dimensions affect social life clearing discursive space amid a field governed by the power of aesthetic judgement enables a rational discussion of issues that exceed that of artistic quality on the other hand the conceptual clearing discursive space amid a field governed by the power of aesthetic judgement enables a rational discussion of issues that exceed that of artistic quality peerreviewed article toni kotnik apparatus might also help architects verbalise their tacit knowledge and so to defend their strivings peerreviewed article toni kotnik

urbanity is a frequently but often vaguely used notion in both urban design and social science my intention is to contribute conceptually and programmatically to attaining a richer urbanity by analysing its traditional character and some literature treating it such as jane jacobss classical work the assumption behind my conceptual clarification and conceptual development is thus that the current confusion of ideas not only hampers informed public and academic discussion on planning objectives but also adversely affects its results even in cities with a strong planning organisation such as helsinki in elucidating the concept i shall distinguish between architectural and social urbanity one may identify a rudimentary variant of the former centring on efficient landuse and rough functional synergy a more sophisticated conception supporting a socially wellworking environment requires an account in design terms including notions such as efficiency and synergy but also the key concept of diversity vital for urbanity in a social sense complications still appear when concretising the notion different types of diversity may conflict there may be competing diversityrelated values and diversity may degenerate into chaos or meaningless discord scale may affect the relative benefits of diversity and homogeneity to clear up some of the puzzles i shall present a minimal but strict interpretation of architectural urbanity building on prototypical traits of the traditional european city and compare the account especially with jacobss discussion key elements of such prototypical urbanity are the public street space delimited by perimeter blocks communicating ground floors and small building units while the idealtypical character of the description entails some normativity of sorts in picking up features considered essential it should be intuitive enough not to be easily dismissed nonetheless if genuine urbanity is sought for the account once accepted takes on a more clearly normative role shifting the burden of proof to anyone suggesting solutions deviating from it this also holds for jacobss ideas if not refuted thus if one acknowledges her prescriptions as scientifically rational and the nature of such knowledge as professionally binding architectural solutions contradicting it are unacceptable even when resulting from apparently diversitygenerating artistic freedom respecting the guiding function of analytical theoretical and empirical arguments is important not to let tangible interests and strictly sanctioned technical economic and juridical requirements alone condition urban design and planning however if social scientists too disregard or deny the value of such knowledge important questions will remain unexplored among them are architectural urbanity as a precondition for social urbanity and mechanisms impeding its realisation concerning the procedural issue of how to generate architectural diversity and urbanity jacobs sometimes comes close to rejecting planning trusting spontaneous order to emerge from interaction and free enterprise alternatively however detailed steering might have the desired effect a presupposition for successfully using available political or organisational means for producing a truly urban and socially wellworking city is a clear comprehension of the ends pursued the treatment tries to contribute to such an understanding however the task remains of more unambiguously connecting architectural to social urbanity

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background there are many known social inequalities in health including differences in healthy life expectancy and mortality 12 these disparities may be partially explained by a social gradient in a variety of health behaviors including diet obesity physical activity alcohol consumption and smoking 3 4 5 health behavior norms may be learnt within the socioeconomic context with social determinants influencing behavior throughout the life course 6 engaging in the arts is an example of a healthrelated behavior that demonstrates social inequalities 78 arts engagement typically refers to different types of creative activity from actively participating in the arts to more receptive cultural engagement it can also encompass broader creative activities that whilst not always labelled as arts share similar properties of creative skill and imagination in 2019 the world health organization identified more than 3000 studies showing the beneficial impact of arts engagement on mental and physical health and social determinants of health from education to social cohesion and welfare 9 despite growing awareness of the benefits of engaging with the arts there is a social gradient in arts participation previous surveys have found that arts engagement in the united states may differ according to socioeconomic status education and income 11 12 13 similar factors are associated with inequalities in access to health care and health and social outcomes 14 15 16 17 varying engagement in the arts may therefore further contribute to health and social inequalities 8 however the literature on this topic is limited by a number of factors first many previous studies have focused on certain demographic or socioeconomic predictors of arts engagement without always taking into account the broad range of factors that may be related to one another from these studies the most consistent predictors of increased arts engagement are higher levels of education and income 1213 18 19 20 21 22 23 24 there have been extensive efforts to differentiate the effects of education and income on arts engagement and it appears that both independently contribute to engagement levels 2125 however education may be more strongly associated with attending highbrow cultural events whereas income is more strongly associated with other forms of arts engagement 25 further selfidentified social class may be another important factor which should be studied alongside income and education 23 there is also evidence for lower rates of engagement in black than white racialethnic groups 1218222627 still it remains unclear whether raceethnicity has a strong association with engagement after other factors particularly education and income have been taken into account 1821222728 additionally there are other factors that could be associated with arts engagement that have not been investigated in the us to date in the uk there are geographical differences in participation independent of individual demographic and socioeconomic backgrounds 29 further living alone is associated with fewer perceived opportunities to engage in the arts and those with poorer physical and mental health may experience more barriers to engaging 30 as many previous studies of arts engagement in the us are based on the survey of public participation in the arts which does not collect data on physical and mental health these factors have not been investigated moreover in the us most research on predictors of arts engagement has measured engagement with benchmark arts activities as defined in the sppa these activities include attending jazz classical music opera musical or nonmusical plays ballet performances and art museums or art galleries although these activities are not intended to be comprehensive 31 they have repeatedly been used as a metric of engagement in the arts this has led to the perception that arts participation is declining in the us 112232 however when defined more broadly including other types of arts activities and going beyond the nonprofit sector to recognize the many diverse commercial forms of cultural expression participation is not declining and the way in which people participate may instead be changing 133334 there may be a growing gap between arts participation metrics and the ways in which people participate and this could be affecting our understanding of the predictors of engagement 35 therefore in this study we used a large nationally representative sample of adults in the us to investigate predictors of different types of arts engagement specifically we were interested in whether there are social inequalities in engagement in the arts as found in other healthrelated behaviors to do this we tested which demographic socioeconomic residential and health factors were associated with attendance at arts events participation in arts activities and membership of creative groups further in order to differentiate between nonattendance due to a lack of interest versus nonattendance due to barriers or a lack of opportunities we investigated whether similar factors were associated with being interested in but not attending arts events finally we examined whether engagement changed across time from 1993 to 2016 and whether associations between demographic and socioeconomic factors and engagement changed over these two decades methods sample participants were drawn from the general social survey a repeated crosssectional and rotating panel study of adults aged 18 and over in the us 36 each survey year was an independently drawn sample of englishspeaking individuals living in noninstitutional arrangements from 2006 onwards spanishspeakers were added to the target population full probability sampling was employed and surveys subsampled nonrespondents from 2004 onwards we used data from gss waves at which arts outcomes were measured between 1993 and 2016 each wave included a unique sample of individuals so we were able to combine data across waves we used four indicators of arts engagement each measured in different waves of the gss arts events were measured in 1993 1998 2002 2012 and 2016 arts activities were measured in 1993 1998 and 2002 creative groups were measured in 199319942004 and 2010 and interested nonattendees were measured in 2012 and 2016 we therefore identified four samples one for each outcome when combining samples across all relevant years the total number of participants was 14890 7203 12311 and 7687 for arts events activities creative groups and interested nonattendees respectively we then restricted the sample just to participants with complete data on arts variables which produced a final sample size of 8684 for arts events 4372 for arts activities 4268 for creative groups and 2061 for interested nonattendees all participants gave informed consent and this study has institutional review board approval from the university of florida and ethical approval from university college london research ethics committee arts engagement outcomes arts events participants were asked whether they had attended arts events in the last 12 months not including school performances in 1993 attendance at three events was measured as the following a art museum or gallery b ballet or dance performance and c classical music or opera performance in 1998 and 2002 two additional events were added to this list d popular music performance and e nonmusical stage play performance in 2012 and 2016 attendance at two types of event was measured a music theatre or dance performance and b art exhibit due to these differences in measurement across years we collapsed all responses into a binary variable indicating attendance at any event in the last 12 months as this does not entirely account for the changes in question style we tested whether the changing definition of arts events altered our findings in sensitivity analyses for full details of the questions asked in each wave see supplementary table 2 arts activities participants selfreported whether they participated in any kind of arts activity in the last 12 months including a making art or craft objects b taking part in music dance or theatrical performance and c playing a musical instrument this was coded as a binary variable and was measured consistently in 1993 1998 and 2002 creative groups participants were asked about the groups or organizations of which they were a member in 1993 1994 2004 and 2010 the creative groups were hobby or garden clubs and literary art discussion or study groups a binary variable was created indicating membership in either of these group types interested nonattendees in the 2012 and 2016 gss participants who responded to the arts event questions were also asked if there was an arts event during the last 12 months that they had wanted to go to but did not attend in 2012 only participants who had not attended an event during the last 12 months were asked this question in 2016 all participants who were asked about arts event attendance were also asked whether there was an event that they had wanted to go to but did not attend as we aimed to include only participants who were interested nonattendees we excluded those who reported attending an arts event in 2016 exposures we examined whether a range of demographic socioeconomic residential and health factors were associated with arts engagement demographics included age sex raceethnicity and marital status socioeconomic factors included total number of years of education parental years of education employment status in the last week family income in constant dollars subjective satisfaction with financial situation and a subjective rating of social class residential factors included level of urbanicity number of people living in the household and whether there was an area within a mile of their home where they would be afraid to walk alone at night finally we included a general health rating statistical analyses we used four logistic regression models to test crosssectional associations between demographic socioeconomic residential and health exposures and binary arts engagement outcomes each outcome was modelled separately where there was evidence of a nonlinear association between age and arts engagement we included a quadratic age term as a number of similar exposures were included multicollinearity was assessed to ensure that variance inflation factors were less than 10 37 all analyses were weighted to account for the subsampling of nonrespondents and the number of adults in the household using weights supplied by the gss 36 we accounted for clustering of participants within primary sampling units by using robust standard errors we also tested whether there was any evidence that associations between arts engagement outcomes and age raceethnicity class income and sex differed over time we included an interaction term between each exposure and survey year in separate logistic regression models where there was evidence for an interaction we then examined the association between the exposure and arts engagement separately in each survey year for participants with missing data on exposures we imputed data using multiple imputation by chained equations we used linear logistic ordinal and multinomial regression and predictive mean matching according to variable type generating 50 imputed data sets the imputation model included all variables used in analyses auxiliary variables and the survey weights auxiliary variables were split ballot group interviewers rating of the respondents attitude toward the interview and understanding of questions respondents rating of their family income and geographic mobility since age 16 imputations were performed separately according to survey year for creative groups several exposures and an auxiliary variable were missing for all participants in some years so were not included in the imputations or analyses all other variables were successfully imputed the results of analyses did not vary between complete cases and imputed data sets so findings from the imputed data are reported all analyses were performed using stata 16 39 sensitivity analysis we tested whether the changing definition of arts event attendance altered our findings in this analysis we used the most homogenous measures of arts events those included from 1998 to 2016 we therefore repeated the main analysis excluding participants from 1993 and examined whether similar factors were associated with arts event attendance in this subsample results arts events in total 8684 participants provided data on attendance at arts events 53 of whom were female and 78 were white these participants ranged in age from 18 to 89 years with a mean age of 466 overall 56 had attended an arts event in the last 12 months although this varied across years in the logistic regression model there was evidence for associations between several demographic factors and attending arts events females had 24 higher odds of attendance than males in comparison to white participants black participants had 34 lower odds of attendance participants who had never been married had 37 higher odds of attendance than those who were married there was evidence that several socioeconomic factors were associated with attendance compared to those with a family income of less than 10000 participants in all other income groups had higher odds of attendance the highest odds were in the highest income group subjective rating of social class was also associated with attendance with higher classes associated with increasing odds each additional year of education was two residential factors were associated with attendance compared to those living in medium to large cities the odds of attendance reduced with decreasing level of urbanicity the odds of attendance were lowest in smaller areas or open country additionally for each additional person in the household participants had 5 lower odds of attendance participants who rated their health as fair or poor had lower odds of attending events than participants who rated their health as excellent finally the results suggested that event attendance varied across survey years although there was no clear time trend in comparison to 1993 the odds of attendance were higher in 1998 2002 and 2012 but did not differ in 2016 arts activities overall 4372 individuals reported whether they had participated in arts activities these individuals ranged in age from 18 to 89 years with a mean age of 448 about 53 were female and 81 were white on average 54 reported participating in at least one arts activity in the last 12 months and this was relatively stable across time fewer factors were associated with participation in arts activities than with attendance at arts events females had 171 times higher odds of participating than males both black and individuals of other racesethnicities were less likely to report participating than those who were white individuals who were unemployed or not working had higher odds of participating than those working as with attending arts events increased years of education and parental education were both associated with higher odds of participating in arts activities there was no evidence that any other factors were associated with participation creative groups membership of creative groups was reported by 4268 participants who were similar demographically to participants who reported other arts outcomes membership in creative groups was lower than attendance at events or participation in activities overall 19 of participants reported being a member of a creative group and this may have decreased over time despite a lower proportion of participants being members of creative groups membership was associated with similar factors to arts activities females had 133 times higher odds of membership than males there was also evidence that the odds of membership increased with more education and parental education in contrast to arts activities those who were never married had 158 times higher odds of membership than married participants and the odds of membership increased with age finally there was evidence that membership decreased over time with the odds decreasing by 32 from 1993 to 2010 interested nonattendees overall 2061 participants reported whether there was an arts event that they had wanted to go to but did not attend 29 of whom were interested nonattendees the proportion of interested nonattendees remained consistent across years as with attendance at arts events there was evidence that being an interested nonattendee was associated with raceethnicity and years of education other racesethnicities had lower odds of being an interested nonattendee than white individuals and the odds of interested nonattendance increased with level of education however in contrast to event attendance those who were more or less satisfied with their financial situation had lower odds of being an interested nonattendee than those who were not satisfied at all there was no evidence that being an interested nonattendee was associated with gender marital status employment status family income social class parental education level of urbanicity household size or general health rating odds ratios and 95 confidence intervals are displayed for associations between sex and arts events the odds ratio represents attendance in females compared to males for associations between raceethnicity and arts events white is the reference category associations were estimated in the full logistic regression models but only results for sex and raceethnicity are presented change across survey years next we tested whether associations between arts engagement outcomes and age sex raceethnicity class and income differed over time there was no evidence for interactions between survey year and any exposures on participation in arts activities membership of creative groups or being an interested nonattendee there was also no evidence for interactions between survey year and age class or income on arts event attendance however there was evidence for an interaction between survey year and sex on event attendance there was no linear time trend as females had higher odds of attendance than males in 1993 and 2002 but there were no sex differences in other survey years there was also evidence for an interaction between survey year and raceethnicity on event attendance black participants had lower odds of attending than white participants and this difference increased over time sensitivity analyses we have reported findings based on imputed data but the results of analyses did not vary when limited to complete cases as shown in supplementary table 4 in our sensitivity analysis limiting the sample to the most homogenous definitions of arts event attendance did not substantially alter our findings discussion in this study we examined whether there are social inequalities in engagement in the arts as found in other healthrelated behaviors 3 4 5 between 1993 and 2016 approximately half of our sample reported attending arts events and a similar proportion participated in arts activities in the smaller sample of individuals who completed the gss in 2012 and 2016 another one third were interested nonattendees who had been interested in attending an event in the last year but had not gone to it fewer people were members of creative groups with approximately one fifth of the sample between 1993 and 2010 reporting group membership several demographic factors were consistently associated with engagement in the arts for example engagement was higher in females than males and married individuals were less likely to engage than those who had never married attendance at arts events and participation in arts activities also differed according to raceethnicity although creative group membership did not socioeconomic factors showed mixed associations with the different types of arts engagement higher levels of education and parental education were consistently associated with all types of engagement attendance at arts events was also associated with higher income and social class better health and living in more urban areas however being an interested nonattendee of arts events was not associated with these factors in contrast to arts events we found no evidence that income social class health or urbanicity were associated with participation in arts activities and groups most of our findings are consistent with previous research demonstrating that a number of demographic and socioeconomic factors are associated with engagement in the arts 13 our findings further advance previous research by using a broader definition of arts to more accurately reflect the breadth of engagement in the us the associations between several demographic factors such as sex and marital status and engagement in all forms of the arts are consistent with previous evidence 19 40 41 42 43 44 we also found that raceethnicity was more strongly associated with participation in arts activities than events as shown previously 22 this association was independent of socioeconomic factors so is unlikely to be explained by overrepresentation of ethnic minorities in lower socioeconomic status groups 45 a report that also used gss data found that lower attendance at arts events by racialethnic minorities may be a result of barriers such as being unable to get to the venue and not having anyone to go with 23 these individuals were also more likely to state celebrating their cultural heritage as a reason for attending events than those who were white 2346 however in this study we found that other racesethnicities were also less likely to be interested nonattendees of arts events than white individuals although this could be a result of the way in which arts events were defined it may also indicate that some ethnicracial groups are less interested in attending arts events a lack of cultural equity cultural relevance interest and inequalities in access are therefore likely to contribute to the racialethnic differences in arts engagement overall our findings support previous evidence that education is most strongly associated with engagement in the arts 1213 18 19 20 21 22 23 24 however contrary to some recent evidence we did not find that education was more strongly associated with attending events than other forms of arts engagement 25 education may increase engagement by helping to cultivate cultural tastes and preferences raising awareness of activities and increasing cognitive capacity to engage 47 arts education specifically may also contribute to this association as it is strongly related to both level of education and arts engagement 2027324849 we found a similar association with parental education independent of the individuals own education although the magnitude of association was smaller this indicates that childhood socioeconomic status continues to influence engagement in the arts throughout the lifecourse children of parents with more education may benefit from increased access to the arts during development and may be more likely to receive arts education in childhood these individuals may therefore have more training and experience enabling them to participate in more highly skilled arts activities consistent with previous evidence for a social gradient in arts engagement we found that attendance at arts events was less likely with lower income and social class poorer health and less urban areas as being an interested nonattendee was not associated with these factors they are likely to be barriers specifically to attendance individuals across the range of incomes social classes health and levels of urbanicity were interested in attending events at similar rates but actual attendance differed according to these factors previously individuals with lower household income and social class were more likely to report barriers to attending events of cost and difficulty of getting to a venue as well as a lack of time 2346 other research has demonstrated that individuals with poorer physical health may experience more barriers affecting their perceived capabilities to engage 30 areas that are more urban such as cities are likely to have a larger range of arts events on offer including at a variety of times and costs as well as appealing to a broader audience and events may be more geographically dispersed or easier to attend using public transport urbanicity can thus be interpreted as a proxy measure for the availability of arts events however there are also likely to be arealevel factors related to the availability and accessibility of the arts that although not measured in the gss require further investigation in contrast to arts events we found no evidence that income social class health or urbanicity were associated with participation in arts activities and groups these types of engagement may be more widely available include more diverse activities be cheaper to participate in and often do not require attendance at a specific venue which may be hard to reach or not generally attended by certain groups there was some mixed evidence for a social gradient in interest in arts events individuals with higher levels of education were more likely to be interested nonattendees as were people who were more or less satisfied with their financial situation previous research has suggested that of the different types of arts engagement education is most strongly associated with highbrow cultural events 25 which could explain the association with interest in events it is unclear why we found evidence for an association with financial satisfaction we might conclude that individuals who were satisfied with their financial situation were not interested nonattendees because they were financially able to attend any events of interest but we found no evidence that financial satisfaction was associated with actual event attendance additionally there was no evidence that being an interested nonattendee was associated with income or differed between those who were pretty well satisfied and not at all satisfied with their financial situation the relationship between interest in the arts subjective measures of satisfaction with financial situation and more objective measures of income thus requires further investigation we also investigated changing patterns of arts engagement as there has been concern that arts participation is decreasing in the us 112232 we found some evidence that event attendance changed over time but this was likely a result of changes in the measure of event attendance as there was no linear trend in contrast group membership decreased over time additionally the racial disparity in event attendance with an overrepresentation of white individuals compared to those of racialethnic minorities increased from 1993 to 2016 these increasing racialethnic inequalities in arts event attendance were independent of other socioeconomic factors such as income and education however given the nature of structural racism this finding should be interpreted cautiously and requires replication in studies with consistent measures of event attendance as this study spanned a period of 23 years with event attendance and group membership measured at different times specific social and economic events in each year could also have contributed to the changing patterns of arts engagement our findings have implications for understanding health and social inequalities in the us a number of the factors that we have identified as associated with arts engagement are also associated with inequalities in access to health care and health outcomes 14 15 16 17 this could be because arts engagement is a correlate of health with both representing a form of capital that can be obtained by individuals with more material resources such as income and nonmaterial resources such as social support 47 consistent with this we found evidence that poorer selfreported health was associated with lower attendance at arts events although it was not associated with interest in attending events or participation in arts activities arts engagement could also represent a health behaviour that leads to improved health outcomes there is growing evidence that engagement with the arts can lead to a range of health benefits independent of demographic and socioeconomic factors 950 it is thus concerning that we have found evidence for differential engagement in the arts future research should explore why engagement is lower in these groups in particular males racialethnic minorities and those with lower education this is particularly important given that previous efforts to reduce inequalities in access to cultural events by expanding facilities and offering free tickets in brazil have not been successful 51 future research could also investigate whether removing other barriers to engagement such as providing the arts online to avoid high prices and reduce time constraints could increase levels of engagement 52 this could then support the development of interventions to promote engagement in the arts and test whether this leads to improvements in health outcomes this study has a number of strengths the gss was a large nationally representative sample and we included several measures of arts engagement although the gss has previously been used to study arts engagement 2343 research has not generally examined membership of creative groups in comparison to other forms of engagement or combined data across as many waves of the gss as in this study we tested a range of factors that may be associated with arts engagement and mutually adjusted for these variables in our models using multiple imputation means that missing data should not have influenced our findings however this study also has a number of limitations we tested crosssectional associations and thus cannot rule out the possibility of inverse causality there are some factors such as health which may have a bidirectional association with arts engagement additionally the gss did not measure attendance at arts events consistently across waves which is likely to explain the association we found between event attendance and survey year a broader definition of arts events was used in later years however when limiting our analyses just to this broader definition our findings were consistent although our measures of arts engagement were more inclusive than in many previous studies they were likely still too narrow standard arts engagement questions are not able to capture arts engagement in some immigrant communities 35 and also typically do not cover engagement in digital or electronic arts activities such as graphic design photography filmmaking and music production this could have contributed to our findings of lower arts engagement in individuals who were not white and underrepresented arts engagement amongst younger generations future research should aim to measure diverse aspects of arts engagement particularly as the us moves towards a majorityminority society in which the nonhispanic white population will no longer form the majority of the us population 53 conclusions given the potential importance of engagement in the arts for health and wellbeing 9 individuals should be provided with equal opportunities to participate our findings indicate that social determinants may influence engagement in the arts throughout the life course encouraging arts activities and creative group membership may provide one way of widening participation and reducing social inequalities in arts engagement it will also be important to recognize that lack of participation may not merely be due to a lack of interest or motivation but may be influenced by structural barriers such as racism or a lack of opportunities indeed the nature of many arts activities that take place in well defined arts spaces are rooted in white supremacy creating a foundational barrier for black indigeouns and other people of color groups future research is needed to identify what these barriers are and how they can be removed this is particularly important in the wake of covid19 given the closure of many arts venues and the disproportionate effect on bipoc individuals and those of lower socioeconomic status 28 54 55 56 additional file 1 authors contributions jkb fb and df designed the study jkb conducted the analysis and drafted the manuscript jkb fb mef ep jks and df contributed to the writing made critical revisions and approved the final manuscript funding the epiarts lab a national endowment for the arts research lab at the university of florida is supported in part by an award from the national endowment for the arts the opinions expressed are those of the authors and do not represent the views of the national endowment for the arts office of research analysis or the national endowment for the arts the national endowment for the arts does not guarantee the accuracy or completeness of the information included in this material and is not responsible for any consequences of its use the epiarts lab is also supported by the university of florida the pabst steinmetz foundation and bloomberg philanthropies df is supported by the wellcome trust 205407z16z competing interests the authors declare that they have no competing interests

background engaging in the arts is a healthrelated behavior that may be influenced by social inequalities while it is generally accepted that there is a social gradient in traditional arts and cultural activities such as attending classical music performances and museums previous studies of arts engagement in the us have not adequately investigated whether similar demographic and socioeconomic factors are related to other forms of arts engagement methods using crosssectional data from the general social survey gss in the us we examined which demographic socioeconomic residential and health factors were associated with attendance at arts events participation in arts activities membership of creative groups and being interested in but not attending arts events we combined data from 1993 to 2016 in four analytical samples with a sample size of 8684 for arts events 4372 for arts activities 4268 for creative groups and 2061 for interested nonattendees data were analysed using logistic regression results more education was associated with increased levels of all types of arts engagement parental education demonstrated a similar association being female compared to male was also consistently associated with higher levels of engagement attendance at arts events was lower in participants with lower income and social class poorer health and those living in less urban areas however these factors were not associated with participation in arts activities or creative groups or being an interested nonattendee conclusions overall we found evidence for a social gradient in attendance at arts events which was not as pronounced in participation in arts activities or creative groups or interest in arts events given the many benefits of engagement in the arts for education health and wider welfare our findings demonstrate the importance of identifying factors to reduce barriers to participation in the arts across all groups in society

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introduction the social constructivist view of gender posits that gender is not an inherent trait of an individual but rather is constructed through social interactions this distinction puts the focus on the actions of individuals and importantly the institutions and social network members that ascribe meaning to those actions additionally this view sees power inequalities as central to understanding gender and associated dynamics in the past two decades masculinity theorists have focused on these power inequalities including those between societys constructed hegemonic masculinity and the other types of masculinities the influence this system of power has on almost all males in a society is extremely important to their behaviors as men weigh how to act in a particular situation their position in this power structure and their desire to maintain position or advance will typically play a role in how they behave in this paper we explore these theoretical concepts of gender and power within mens social interactions using data collected from indepth interviews with thirty men in the dominican republic specifically we aim to explore how masculine norms influence mens social interactions and how those interactions drive mens sexual behaviors and use of violence previous work on caribbean and dominican masculinities de moya a prominent dominican masculinities scholar wrote about the socialization of dominican males into the prevailing standards of masculine behavior he posited that masculinity is a totalitarian regime that controls the lives of dominican boys and young men de moya used participant observation and interviews with men and women to identify the rules associated with being a normal boy in the dr including he cannot publicly show fear of anything he should not sob nor cry even when hurt and he should show a vivid and visible erotic interest in all females who come close to him when he is with his peers these behavioral ideals are instilled in young dominican boys and enforced by others through punishment and shaming during youth and adulthood as de moya states dominican males are socialized in a strongly restrictive and prohibitive environment which surely cripples their spontaneity authenticity and joy and produces hypocrisy and neurosis thus these rules not only stifle men but may also cause a considerable amount of stress as they attempt to meet the rigorous standards of manhood pleck refers to the effects of this stress in his masculine gender role strain paradigm those men who do fit neatly into the masculine ideals may feel stress to maintain that status and those who do not fit may feel the same stress as well as discrimination and shame related to not fitting the ideal while de moyas research focuses on a singular dominant ideal masculinity other scholars within the dr and the region have identified two distinct ideals that are often in conflict with each other this idea was first proposed in the region by anthropologist peter wilson and later applied in jamaica by whitehead wilsons framework posits that men are subject to two interconnected value systems that he calls respectability and reputation a mans reputation is judged by his male peers and depends on his masculine activities the masculine activities include sexual prowess athletic competition strength seducing women and fathering children a mans respectability on the other hand is judged by the entire society and tends to be based on european middleclass values to be respectable a caribbean man needs to conform to the rules set by the church and government as well as work hard provide for ones family and participate positively in the society wilson notes that both together make up a single system and that they are dual and contradictory other scholars have similarly noted competing gender norms such as the casacalle norms in the dr and homosocial heterosocial social spaces in mexico men are socially rewarded for being both respectable and reputable and thus must fulfill both norms even when they conflict in terms of healthrelated risk behaviors the reputation are where group dynamics exist that facilitate promote sexual risk behaviors and other potentially harmful behaviors such as violence and alcohol abuse our teams previous empirical research with men in the dr has explored several dimensions of the relationship between mens social networks and risktaking behaviors a mixedmethods study with male steady partners of female sex workers in la romana dr found that mens sexual risktaking was influenced by their perceptions of their peers risktaking and the social influence exerted by those peers through social network interactions we subsequently conducted a qualitative exploration of mens peer group relationships focusing on male peer groups and homosocial spaces and found that most men lacked trusted friendships and many avoided friendships due to perceptions that peers would pressure them to behave in ways they did not want to we also found that mens sexual behaviors and willingness to get tested for hiv is in part shaped by concerns of projecting a masculine image of strength to their social network these theoretical perspectives and our previous research indicate that mens social interactions play a crucial role in influencing mens behaviors in the dominican republic however we lack a nuanced understanding of how men perceive and describe these social interactions and the specific mechanisms by which masculine norms influence mens sexual and violent behaviors the current study aims to fill these gaps methods study setting and context we conducted indepth interviews with thirty men in two cities in the dr santo domingo and la romana santo domingo is the capital and financial center of the dr and has an estimated population of 22 million people la romana is the third largest city in the dr with a population of approximately 250000 and is located on the southeastern coast near many popular international tourist destinations the surrounding areas are also home to a large haitiandescendent community who live in bateyes and work in sugar production we conducted our research as part of a larger study which aimed to assess the feasibility of offering voluntary adult male circumcision as an hiv prevention strategy in the context of primary care settings in the dr recruitment and data collection our sample of thirty men was drawn from men who attended their followup visit for the parent study the parent study used referrals and community outreach to find men who were 1840 years old and were willing to undergo a circumcision to reach a sample at heightened risk for hiv female sex workers in both sites were asked to refer their sexual partners and in la romana one recruiter was dedicated to recruiting men from nearby bateyes followup visits for the parent study occurred between july 2013 and march 2015 we conducted indepth interviews with all available men that came to their followup visit in may or june 2014 until all 30 interviews were conducted and the study team determined that we had reached saturation of themes men were reimbursed for their travel to the clinic interviews were audiorecorded and conducted by the firstauthor in spanish using a semistructured interview guide the interviewer is a white male in his thirties with experience conducting qualitative interviews with men in latin america on topics of gender and masculinity he is a fluent nonnative spanish speaker apart from questions related to mens experience in the parent study the interviews focused on three overarching questions how does the man define manhood in the dr to what extent does the man want to be perceived as masculine by important others and how do interactions with other men shape his own behaviors all study procedures and protocols were approved by the institutional review boards at the university of illinois at chicago the university of north carolina chapel hill and the instituto dermatológico dominicano y cirugia de piel dr huberto bogaert díaz in santo domingo dr data analysis qualitative data analysis was iterative starting with the completion of the first interviews and continuing throughout the data collection and writing process after each interview the firstauthor wrote field notes about the interview and memoed about notable things the participant said or did interview questions and probes were modified in response to observations from early interviews audio recordings of interviews were transcribed verbatim in spanish after transcription the firstauthor read through each transcript while listening to audio to identify key themes and stories and discussed preliminary findings with coauthors and the study team for each participant the firstauthor wrote a brief summary of each participant using available details from the their life and then wrote analytic summaries of what the participants said related to key areas of interest this process served to contextualize the meanings of manhood and other key concepts within the life of individual participants subsequent to writing these summaries we developed a codebook with deductive codes derived from the interview guides and inductive codes based on themesideas identified in our memos and summaries for example deductive codes included meanings of manhood and violence and inductive codes included humiliation and selling yourself we coded the transcripts using the atlasti software the code outputs for key themes were used to systematically assess and deepen our understanding of ideas in the summaries using the narratives and code outputs we prepared matrices for the analysis of patterns across the study population and for comparisons between subgroups we integrated memo writing throughout this process to facilitate the interpretation of the data and to provide an audit trail of the analysis to document our interpretations after reviewing all memos analytic summaries and matrices we identified prevalent narratives and themes that responded to our research question findings are described below using illustrative quotes with pseudonyms in the results section we operationally define the terms common many men or men often as referring to more than half of participants and some or few men to refer to themes reported by less than a quarter of participants results we interviewed 30 men 15 men in each study site between the ages of 20 and 40 most men were partnered employed in either the formal or informal labor market and had at least secondary education we first describe how masculine norms emphasizing competition shaped mens interactions with their peers and then how this competition is dependent on social context finally we demonstrate how this competition and specifically mens fear of being humiliated and social pressure to respond to instances of humiliation shaped mens decisionmaking around sexual and violent behaviors competition and the importance of social context men described that being perceived as masculine was not simply about meeting certain expectations of manhood but also that they additionally needed to successfully compete against other men while hector said he was fulfilling the masculine role of providing for his family he additionally highlighted the importance of success relative to other men in his social network you have to always do things well…try to feel equal to them if he tried to be more of a man than you you cant just stay behind him you have to show him that you are equal to him make him see for example that what he can achieve you can also achieve in addition to being a provider hector also felt the need to keep up with other men in his network thus portraying a masculine identity was both about performing certain behaviors and about performing certain behaviors better than other men what men competed about depended on their own personal priorities in a given social context but typically reflected normative masculine characteristics such as a capacity to earn money purchase material goods attract or satisfy sexual partners or have multiple sexual partners daniel a 21year old university student commented that successfully competing required that men including himself could adapt themselves to emphasize different masculine characteristics depending on their social context because different social groups placed varying degrees of value on each characteristic he said a mans portrayal of masculinity depended on which group hes going to sell himself to… there are different ways a man can be perceived thats what he ends up selling many mens comments highlighted the importance of context below we use the story of erick a 20year old street vendor who lived with his wife and young son as a case example of how men described varying their behaviors depending on the expectations of a particular social group erick lived in a closeknit community on the outskirts of la romana and like most men worried about being able to provide for his young family im not going to feel content knowing that i have a son a woman that arent eating well that i cant even buy a pair of shoes or nothin while he was sincerely concerned about the wellbeing of his family he also worried about the bad impression his neighbors would have if he was not adequately providing for his family he said i worry that people are talking humiliating me making me feel lesser look at him he had his family look now how hes fallen they cant buy anything they cant eat well and theyre getting too skinny he described how this fear of not being able to provide for his family and fear of others gossiping about him was a constant worry for him because this fear was related to his social status his neighbors valued the provider masculine role and also devalued the calle street masculinity that emphasized violence and sexuality when asked how he could demonstrate his masculinity to his neighbors erick responded dont be causing trouble in the calle so that no one talks bad about you he was concerned that if he got into fights or was known to have extramarital relationships he would lose social status among his neighbors erick articulated that his neighbors valued men that were responsible fathers and provided for their families and he tried to adapt his behaviors accordingly while his neighbors were one important social group for erick his friends were also extremely important in his life he described that he and his group of friends grew up together and they were like family to him despite this familial intimacy erick had with his friends he said that there were situations when he needed to use violence to demonstrate his masculinity to them there are always people that think they are more manly than you they start getting fresh confrontational and stuff you perpetrate violence so that you arent standing there with your arms crossed so that you can demonstrate to him that you too are a man…thats what happens with this type of violence when you have five or six friends and you want those friends to respect you youve got to prove that in front of everyone you are more than them you can do that through violence ericks friends expected him to use violence for instances when other men were confrontational and challenged his masculinity for erick the social value of perpetrating violence depended on his context it inhibited his ability to compete for social status among his neighbors but enabled him to gain social status among his friends this contradiction played out in the lives of many men in our study who each belonged to various social groups with different behavioral expectations humiliation is a key element of competition these conflicting norms and the importance of successfully competing with other men to gain social status caused men to worry about being humiliated men used the word humiliation to describe instances where their status value or respectability was called into question typically these were direct threats on their manhood thus it was a tool for competition since instances of humiliation severely restricted a mans ability to successfully compete with peers these humiliations were by nature public affairs that typically resulted in their social network members talking negatively about the man and were related to the normative characteristics of manhood discussed above men referred to examples often occurring at drinking establishments where another man would bump into them shove them or say something to humiliate them in front of their friends or girlfriendwife female partners could also humiliate men by not showing sufficient deference in public benito describes one example of another man being confrontational when he was with his girlfriend i was with my girlfriend buying some sandwiches and three guys passed by my side and i accidentally ran into one of them i turned around and said excuse me and…the guy got aggressive and he poked me like this in the chest he gestures a forceful poke in front of my girlfriend thats humiliating he did it precisely to humiliate me so that my girlfriend would see that she was with a coward this type of humiliation was considered a challenge to mens status because it was emasculating to be disrespected mens sexual relationships with women were another potential source of losing respect and feeling humiliated most men said that the biggest humiliation would be if a mans wife or girlfriend was unsatisfied sexually or was cheating on him with another man edwin a 39yearold man who had been married for 22 years described why it was important for him to satisfy his wife if i dont make my wife satisfied shes going to satisfy herself somewhere else thats the problem you know i have to try and satisfy her so that she doesnt leave me for someone else for edwin if his wife cheated on him that would be a signal for him and for others in his social network that he was not satisfying her sexually a cheating partner was considered the ultimate form of humiliation because it indicated a failure to fulfill one of his obligations as a man men described that lasting long was a marker of whether or not a man could satisfy his wife luis a 21yearold unemployed man who lives with his parents described how conversations with friends about lasting long caused men to worry about being humiliated during future sexual encounters sometimes you hear soandso saying no i did this and that and i lasted a half hour having sex i lasted 20 minutes and you think soandso lasted a half hour but i cant even last 5 so you worry and try to figure out whats going on whats the normal time to last luis curiosity about the normal time to last reflects his need to compare himself to others but also reflects the somewhat mythical nature of mens sexual performance given that it is typically a private behavior not directly observed by others antonio a 33yearold married man with two kids spoke about how this could lead to humiliation women can start talking so that worries a man that theyll say something about him that hes a goodfornothing man and that you dont make your woman feel good in bed these things can cause a woman to look for other partners you know this gossip happens a lot and it worries men…because everyone is going to look at you as a joke again even though sexual behaviors are typically private between two partners this gossip about sexual performance was common and allowed members of mens networks and their potential sexual partners to assess the mans sexual capabilities an indicator of his masculinity antonios comments emphasize how central a mans sexual performance and specifically capacity to satisfy ones partner is to a mans social status and ability to avoid being humiliated responses to humiliation mens responses to this humiliation shaped their sexual and violent behaviors while a few men said they were able to ignore instances of humiliation most said that a man must respond or react when humiliated benito described that a man needs to respond in order to ensure that he does not lose status the man that lets himself be humiliated by another man loses his value in front of everyone else he loses respect or at least what they understand is respect in front of everyone else so if a man doesnt respond to a humiliation he can lose his value as a man responding to an instance of humiliation is about saving face recouping ones masculinity and ensuring that social status is recovered how men responded to instances of humiliation were important for their sexual and violent behaviors below we describe three common responses perpetrating physical violence humiliating the other person and taking actions to prevent it and their implications for behaviors first the most commonly described way that men responded to humiliation was with physical violence felipe a 22year old married man said its really common for guys to respond with violence its rare that someone humiliates you and you can stay calm no you have to do something to get even because you feel bad about yourself because of what the other person did this physical violence perpetration allowed men to get even and recoup their masculinity in the case of benito who was humiliated by a group of guys in front of his girlfriend he violently threatened them i showed them my gun to scare them off and show them he was not a coward men also commonly reported that perpetrating physical violence against women was often in response to humiliation from their female partners jose said a man becomes violent because a woman says youre a goodfornothing i dont feel good when im with you so that causes conflict while only a few men seemed to express tolerance for physical violence against women men described perpetration of physical violence against women as a common response from men in their community to instances of humiliation from women when physical violence perpetration was used to respond to humiliation it represented the easiest quickest and most obvious way for a man to demonstrate his manhood and superiority to others it is important to note that mens decision to use or not use physical violence in response to humiliation depended on the context and the potential consequences felipe the man who described the importance of violence above described how men had to balance different priorities when considering their use of violence in response to humiliation he mentioned that he was humiliated by his bosses at work they always look for some way to humiliate me or make me feel smaller than them…they are like listen im much better than you you are nothing felipe went on to recount his thought process about how to respond you can humiliate me in my job and i wont do anything because ill lose my job but truthfully i feel humiliated… but if in the calle street you humiliate me ill grab you and hit you with something in this case felipe prioritized earning money and providing for his family rather than demonstrating his capacity for violence and aggression his workplace social environment called for different behavioral norms and expectations for men than the calle environment the second potential response to humiliation humiliating the other person allowed men to avoid the potential negative consequences of perpetrating physical violence men who used this strategy criticized andor perpetrated emotional violence against the person who originally humiliated them which allowed them to recoup social status by calling into question the social status of the other person for example if a woman gossiped about a mans sexual performance the man may spread negative rumors about her benito said that if a man chose not to respond with violence to womens insults about his sexual prowess hell insult her behind her back to try and humiliate her worse than he was i mean hell say that she smells bad down there or something like that this retaliatory response allowed men to respond to the humiliation and recoup their masculine status while avoiding the potential negative consequences of perpetrating physical violence the third strategy was preventing or minimizing instances of humiliation which also had implications for their behaviors men who wanted to prevent humiliation related to confrontations with other men said they avoided bars or nightclubs large groups of friends andor drinking alcohol in contrast men who wanted to prevent humiliation related to their sexual performance used several behavioral strategies to minimize or prevent humiliation first some men commented that they might preemptively change their sexual behaviors in order to avoid being teased pedro a 35yearold man with a steady job in the tourism industry spoke of his decision when he was younger to start having sex with sex workers i went out with friends we paid to sleep with women we were in that environment…its psychological i felt like if i didnt do what the others were doing i wasnt normal…if i were to say no i worried what they would think of me he modified his sexual behaviors as a younger man because he wanted to avoid feeling humiliated in front of his peers second as an alternative to changing actual sexual behaviors some men also exaggerated the truth or deployed lies to safeguard their sexual reputation arturo a 28yearold married man provides an example of this i make something up to make myself look good during that moment of conversation with friends …i could say i was with a woman in a hotel and wow that woman came and came something like that a lie these lies allowed these men to avoid losing the increased social status that was associated with demonstrating sexual prowess finally some other men reported that if they failed to sexually satisfy a partner they sought new sexual opportunities to prove themselves again emilio a 21yearold construction worker said that faced with this type of humiliation a man will try to grab that same chick that started to talk crap about his sexual capabilities and do it with her again so that she can see that it was just only that one day… or theyll try to find other women to prove themselves attempting to have sex with the same sexual partner or find new partners offers the man an opportunity to satisfy the woman and shift the negative gossip about him the existence of multiple behavioral strategies to combat humiliation related to sexual prowess emphasizes the salience of this factor in shaping mens sexual behaviors discussion we found that the relationship between masculine norms and mens sexual and violent behaviors is primarily explained by male competition and avoiding humiliation in our sample men interviewed who successfully navigated how and when to emphasize certain masculine characteristics or behaviors were able to avoid being humiliated and losing social status however success was ultimately defined by mens peers who were aiming to improve their own status and took advantage of opportunities to humiliate other men these dynamics emphasize the fragile nature of being perceived as masculine in the dominican republic these findings align with previous research that has emphasized the fragility of masculinity and that the anxiety it produces is associated with aggression and sexual risk behaviors the concept of precarious manhood was formalized through the research of vandello and colleagues but the idea that men are constantly needing to prove their masculinity has been highlighted by other masculinities scholars vandello and colleagues demonstrate through empirical research with men in the us when men feel their masculinity is challenges they respond with aggression our findings also aligns with research on the culture of honor in southern united states which highlights that perceived slights against men must be responded to with violence to preserve ones reputation men in our study who were humiliated grasped for relatively quick responses such as sex with a new partner or perpetrating violence in order to emphasize their masculinity and recoup their social status thus mens competition and humiliation have implications for mens behaviors their health outcomes and the health of their partners and communities men did not perform a singular coherent configuration of masculine behaviors but rather adapted to each context and varied their performance of masculinity a masculine behavior in one social context could be deemed as unmasculine in another context and thus a man is rarely free from potential humiliation for example some contexts required men to restrain themselves from violence and other contexts encouraged violence perpetration this variation in masculinities is similar to the theoretical concepts of casacalle homosocialheterosocial and reputation respectability in that it recognizes that there is not a singular masculine norm connells theorization of multiple masculinities highlights that different groups of men each have their own configuration of masculinity while this concept emphasizes the grouplevel variations in masculinity our findings and the ideas of casacalle homosocial heterosocial and reputationrespectability indicate that multiple contextspecific masculinities may also be operating within individual men for example the man in our study who chose to back down when being humiliated by his bosses chose to prioritize his ability to provide for his family rather than prioritize his ability to demonstrate his strength and propensity to defend himself though his deference to his boss protected his economic livelihood it also resulted in lower status at work and feelings of frustration and sadness situations like these can cause men anxiety as men are actively concerned about their ability to portray a masculine identity this anxiety and concern about being able to demonstrate masculine characteristics is described in plecks masculine gender role strain theory pleck postulates that cultural standards for masculinity exist and that socialization encourages men to attempt to live up to them he also highlights that masculine gender norms can be conflicting and inconsistent which causes men to worry about their ability to fulfill norms pleck describes several ways that this can result in negative outcomes for men first men who are unable to achieve gender role expectations may suffer from low selfesteem and other psychological consequences in our findings humiliation results from men being unable to meet the gender role expectation and we also found that men reported feeling bad about themselves in such instances pleck also describes that men who have been able to achieve gender role expectations may result in harmful health behaviors because the gender socialization process has caused them to fear transgressing masculine norms in our data we see that men potentially harm themselves in an effort to adhere to masculine norms in a given context it should be noted that our data also find support for the fact that mens concern about being perceived as masculine also sometimes encouraged them to avoid violence and adopt other seemingly healthpromoting characteristics like working and providing for ones family overall the concepts of competition and humiliation are key factors for understanding how masculine gender role strain works to influence mens health behaviors the field of study focusing on masculinities and health has largely ignored how masculine norms and the dynamics of male competition can prevent men from engaging in risky sexual behaviors or violence perpetration we showed that men use both violent and nonviolent behaviors as strategies to demonstrate their masculinity our data unfortunately had no information on whether or not men used sexually protective behaviors as strategies to demonstrate their masculinity future research needs to better understand how competition between men might be healthpromoting across a range of behaviors and outcomes ultimately men need to feel empowered to adopt nonviolent behaviors and not fear that nonviolence may appear unmasculine or inappropriate to certain members of their social networks in some settings women increasingly have a broader range of acceptable behaviors and life choices due in part to public health interventions that empowered women and modified their structural environment similarly more men need to feel that it is acceptable even to friends in the calle to respond to humiliation in healthy or nonviolent ways given the importance of competition health interventions that intervene on gender should not only consider the harmful effects of the hierarchy between men and women but also the hierarchy and competition between men health programming has spent decades attempting to dismantle the hierarchy between men and women due to its detrimental effect on womens health the same effort needs to be made to reduce status hierarchies between groups of men that can encourage competition and humiliation often interventions targeting masculinities aim to encourage men to adopt childrearing tasks or reduce their violence against women but interventions can also begin to breakdown hierarchies between men by also asking men to challenge the idea that nonviolent or sexually impotent men are failures as men elements from the interventions one man can and interventions undertaken by the family violence prevention fund utilize some activities about competition between men however these efforts should be expanded and more widespread such efforts will begin to neutralize the pressure men feel to belong to a specific type of masculinity to avoid being humiliated and losing social status finally future research needs to acknowledge that masculinities are specific to social contexts most current research on masculinities and health utilizes measures to characterize the type of masculinity that a man endorses or adheres to for example research within the field of hiv relies on mens normative beliefs about sexuality but this assessment ignores that masculinity and its corresponding beliefs and behaviors is contextdependent and that multiple masculinities can and do coexist within the same man measures of gender ideology may need to employ vignettes or other innovative measurement techniques to assess contextspecific attitudes additionally measuring constructs like gender role conflict may be more useful than measuring adherence to norms since it gives a better idea about mens internalization of gender norms and how concerned they are to adhere to those norms limitations our study findings and conclusions should be considered with some limitations first our participants were voluntarily enrolled in a study of male circumcision the sample of men who opted to receive a circumcision may differ substantially from a more general population of men second our sample is small and primarily consists of lowincome and loweducation men thus we are unable to tease apart differences between subgroups the issues described in our paper are likely to be different for dominican men with higher education higher income or other factors third this study is exploratory and theorizesand provides empirical evidence for the mechanisms by which masculine norms competition and humiliation contribute to sexual and violent behaviors while our data describe these mechanisms future research is needed to establish any causal relationship finally the data were generated through conversations by participants with the interviewer and the interviewers identity and characteristics likely influenced the types of responses we received though we dont consider this a limitation our data should be interpreted in light of this fact conclusions health researchers and interventionists have made great strides in acknowledging considering and incorporating norms of masculinity into contemporary studies and health promotion efforts with men continuing this forward progress in mens health and the health of their partner and families requires incorporating social dynamics such as competing gender norms into interventions that address male competition and empower men to overcome these negative social influences dissertation fellowship from uncs institute for the study of the americas and the koch travel award from the gillings school of global public health at unc

we use data collected from indepth interviews with men n30 in the dominican republic to explore how mens concern about being perceived as masculine influences their interactions with their social networks and how those interactions drive mens sexual behaviors and use of violence mens sexual and violent behaviors were shaped by the need to compete with other men for social status this sense of competition also generated fear of humiliation for failing to provide for their families satisfy sexual partners or being openly disrespected in an effort to avoid humiliation within a specific social group men adapted their behaviors to emphasize their masculinity additionally men who were humiliated recouped their masculinity by perpetrating physical or emotional violence or finding new sexual partners these findings emphasize the need for understanding these social dynamics to better understand mens violent and sexual behaviors

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introduction the accessible canada act aims to eliminate barriers and to ensure greater opportunities for people with disability in canada specifically the act sets out to create a culture change through monitoring and oversight with respect to access for people with disabilities in areas under federal jurisdiction including buildingspublic spaces employment opportunities informationcommunication technologies delivering public programsservices and transportation developmental disability is a common type of disability defined as an impairment in cognitive function that presents prior to adulthood and persists throughout a persons life the number of individuals impacted by dd in canada is large estimates of the percentage of children in canada with dd have ranged from 65 to 83 and many people with dd experience lifelong limitations that impact their quality of life despite its substantial impact there is a lack of uptodate information on accessibility and inclusion outcomes for people with dd in canada previous analysis has shown that canadians with disability face barriers to employment and education resulting in poorer standard of living outcomes on average than the general public however these findings are based on data collected in 2012 by the canadian survey on disability and it is unclear if they reflect the current reality for people with dd in canada a subsequent version of the csd was conducted in 2017 representing an opportunity to update the literature on outcomes for people with dd we therefore report data on employment education income housing caregivers and use of government benefits for people with dd using the 2017 csd an understanding of the current state of economic and standard of living outcomes for canadians with dd is critical to develop targeted policies to improve the lives of people with dd and also for monitoring canadas progress towards meeting the goals of the accessible canada act for context in canada supports for people with disability are provided by the federal provincial and municipal 1 3 governments and also by notforprofit organizations programs that provide housing and housing supports for people with disability exist across all branches of government in canada additionally notforprofits play an important role in assisting people with disabilities in obtaining housing with respect to education the federal government mandates that children must receive education and that public education must be accessible to all children based on these guidelines each province is left to implement their own system methods the canadian survey on disability the csd is a national repeated crosssectional survey of canadians 15 years of age and above who are limited because of a healthrelated problem or condition csd participants were recruited from individuals who reported having a longterm condition or difficulty on the 2016 census longform questionnaire from this sample people with disability were identified using the disability screening questions the dsq are questions developed by statistics canada and employment and social development canada to identify people with disability from larger samples the 2017 csd classified disability into 10 types consisting of hearing vision mobility flexibility dexterity pain learning mental health memory and developmental disabilities to facilitate further classification csd respondents were asked to report the medical conditions that cause them the most difficulty or limitations to their daily activities to a maximum of two statistics canada recoded the reported conditions with the corresponding international classification of diseases tenth revision code this allowed for the identification of subgroups based on diagnostic classification beyond the 10 types of disability prespecified by the 2017 csd data collected by the csd focused on four broad themes disability characteristics supportsbarriers education and employment additionally statistics canada has linked respondents 2017 csd data with their 2016 census data allowing for a greater range of variables statistics canada has also linked 2016 census data for a sample of the nondisabled population to facilitate comparisons between groups with disability and nondisabled people vetting requirements imposed by statistics canada stipulate that data for samples of less than 10 individuals cannot be released and are replaced with an x in this analysis furthermore data must meet minimum reliability thresholds data with a coefficient of variation between 166 and 333 is marked with an e indicating that readers should use caution regarding the value data with a cv of over 333 cannot be reported and is replaced with an f of note the 2017 csd user guide recommends the cv be calculated by dividing the standard error of an estimate by the estimate itself the 2017 csd was conducted between march 1 and august 31 2017 and was administered using an internetbased electronic questionnaire the 2017 csd had a 695 response rate corresponding to approximately 50000 participants additional information related to the development and administration of the 2017 csd can be found in the surveys user guide sample groups this study focuses on people with dd and provides subgroup analysis of two dd autism spectrum disorder and cerebral palsy asd is characterized by impairments to social interactioncommunication and restricted repetitive behaviors cp is characterized by mental and physical impairments caused by prenatal or early life brain injury outcomes for people with dd are compared to people who reported having any disability and nondisabled people for context the dd group reflects 2017 csd respondents who reported that they had been diagnosed with a developmental disabilitydisorder for ad respondents were limited to those who reported that their disability was likely to be lifelong or of unknown duration as barriers facing people with nontransient disabilities are likely to require different policy solutions than people with transient disabilities the asd group included all those who reported either a primary or secondary condition that was linked to an asd icd10 code asd codes included f840 f841 and f845 the cp group reflects those who reported either a primary or secondary condition that was linked to a cp icd10 code cp codes included g800 g801 g802 g803 g804 g808 and g809 statistical analysis data in the present study is reported using descriptive statistics consisting of means or proportions and their respective 95 confidence intervals additionally in some cases counts are reported estimates of means proportions and counts were weighted at the individual level to reflect the canadian population since csd respondents represent a sample of the larger canadian 1 3 population with disability statistics canada provides a set of 1000 bootstrapped weights unique to each respondent to account for sample variability means proportions and counts presented in the present study reflect an aggregation of these 1000 respondent specific weights analysis was undertaken using stata version 16 with the survey analysis package statistics canada recommends that comparisons for significance of data from the 2017 csd be made using ci calculated with bootstrapped se to adhere to this recommendation the present study provides ci for all means and proportions based on bootstrapped se 95 ci were calculated by multiplying the bootstrapped se rounded to one decimal place by 196 and using this value to create the interval significance can be assessed by whether or not the intervals of two means or proportions overlap as there exist known links between age and sex with employment income and standard of living outcomes and since the distribution of these variables is not equivalent between included groups we conducted exploratory analysis controlling for these variables using ordinary least squares and logistic regression outcomes for which age and sex were controlled for include postsecondary education completion rates employment income and homemaintainer status results demographic information the average age of people with dd is 385 years old six years younger than the average of those without disability and 17 years younger than the average of people with ad the average age of people with asd and cp are 281 and 377 years old respectively while approximately half of nondisabled people in canada are female and 557 of people with ad are female among people with dd more are male notably the female to male ratio for asd is approximately 12 while for cp it is approximately 21 geographically the percentage of people with dd who live rurally is similar to people with ad or no disability however there is a geographic difference in location for specific diagnoses most strikingly only 71 of people with cp live in rural areas the csd defined rural as an area with a population of less than 1000 or a population density of less than 400 per square kilometer table 2 shows the estimated number of people by both category of disability and age demographic in canada people with dd made up 52 of the 5677170 people over the age of 15 with disability the percentage of the canadian population over 15 with dd was 10 and for ad it was 185 for asd it was 02 and for cp it was 01 1 3 table 3 shows the estimated percentage of provincial populations by category of disability interestingly the rate of dd appears to be lowest in the territories region consisting of the northwest territories nunavut and the yukon these are northern regions partially located within the arctic education outcomes people with dd were less likely to complete high school or postsecondary education than nondisabled people and people with ad figure 1 shows the estimated highest level of education attained by category of disability of note respondents can only be in one category in fig 1 for example if a respondent had both a high school diploma and a university degree they would be counted in postsecondary but not high school the percentage of people not completing high school was 400 for dd 183 for ad and 97 for nondisabled people the percentage of people with less than postsecondary was 701 for dd 450 for ad and 331 for nondisabled people educational attainment was similar for people with asd and cp as age and sex are likely to influence if a respondent has completed postsecondary education and these variables are not evenly distributed between people with disability and nondisabled people these variables were controlled for using logistic regression we found odds ratios for dd of 0195 for ad of 0630 for asd of 0300 and for cp of 0250 as these ors are less than one they suggest that the probability of completing postsecondary education is lower for people with disability than for nondisabled people controlling for age and sex each of these ors were significant at a 1 level educational supports are important for ensuring accessibility of education we report educational supports required by people with disability and if supports were received table 4 shows the estimated percentage of individuals who reported having access to a required educational support for the five most commonly required by category of disability the most commonly required supports for people with dd were individualized education plans extended test time modified curriculum technology and a teachers aidetutor there is substantial similarity amongst the most commonly required supports among categories of disability for ad dd and asd the top five most commonly required educational supports are the same though their ordering differs cp differed from the other categories of disability in that people with cp required supports for physical barriers such as accessible classrooms or specialized transportation table 5 shows the estimated percentage of individuals who reported having access to a required educational support for the five least commonly provided by category of disability the five least commonly provided supports for people with dd were accessible residences speech therapists accessible buildings technology and teachers aidetutor of note there is a degree of overlap between the supports reported in tables 4 and5 this indicates that some of the most commonly required supports by people with disability are amongst the least commonly provided asd and cp were not included in table 5 because of suppressed data due to high variability employment outcomes figure 2 shows the estimated labor market outcomes by category of disability for dd 630 of people were not in the labor force 109 were unemployed and 261 were employed in contrast the national averages indicate 342 were not in the labor force 63 were unemployed and 616 were employed people with dd also fared worse when compared to people with ad having lower labor force participation and employment of people with disability who were employed fewer people with dd worked fulltime as 519 of dd were full time 783 of ad were full time 449 of asd were full time and 393 of cp were full time values for national averages are from statistics canada and reflect people 15 and over cp was not included in fig 2 because of suppressed data due to small sample size the 2017 csd asked individuals not in the labor force what barriers prevented them from working table 6 shows the top five reasons given by category of disability the same five barriers were identified for both the dd and ad groups health condition lack of training no jobs available past attempts unsuccessful and a fear of losing current supports though the barriers reported were the same between ad and dd the percentage of individuals reporting a given barrier was higher for dd asd and cp were not included in table 6 because of suppressed data due to both small sample size and high variability the 2017 csd collected data on the workplace accommodations required by people with disability and if respondents received the accommodation table 7 shows the estimated percentage of individuals who reported having access to a required workplace accommodation for the five most commonly required by category of disability for dd the most commonly required accommodations are modified duties modified work hours human support working from home and special computer software cp was not included in table 7 because of suppressed data due to both small sample size and high variability table 8 shows the estimated percentage of individuals who reported having access to a required workplace accommodation for the five least commonly met accommodations by category of disability for dd the least commonly met accommodations were working from 1 3 home chair with back support modified workstation accessible building features and special computer software there was little similarity between the least commonly met accommodations between dd and ad additionally rates at which accommodations were met tended to be lower for dd than ad similar to supports for education there was a degree of overlap between the accommodations reported in tables 7 and8 suggesting that some of the most commonly required workplace accommodations are the least provided asd and cp were not included in table 8 because of suppressed data due to both small sample size and high variability table 9 highlights the top five industries of employment for people with disability using the north american industry classification system by category of disability for dd the most common industries of employment are retail trade healthcare social assistance accommodations food services construction and manufacturing asd and cp were not included in table 9 because of suppressed data due to both small sample size and high variability income and government transfers income is critical to ensuring full participation in society we report estimated before tax employment income government transfers and total income by category of disability people with dd earned less on average than nondisabled people or people with ad this discrepancy exists for both employment and total income the discrepancy was particularly striking for the asd group though people with dd receive more government transfers their total income on average is still only one third of nondisabled people when comparing dd to ad government transfers were 7446 for dd versus 5116 for ad but total income for people with dd was only 406 of people with ad people with cp received more government transfers than people with asd and earned more in total income the poorer labor market outcomes and inadequate government transfers has meant that many people with dd qualify as lowincome when measured using the market basket measure 282 of people with dd 170 of people with ad 241 of people with asd and 376 of people with cp are considered lowincome this compared to the 105 of nondisabled people who earn less than the mbm threshold the mbm measures lowincome based on a households ability to purchase a basket of commonly used goods that corresponds to an acceptable standard of living this does not account for additional costs associated with disability that people without disability would not incur as age and sex are likely to influence employment income and these variables are not evenly distributed between people with disability and nondisabled people we controlled for these variables to see if they contribute to the discrepancy using ols we found differences for ad 30220 for asd and 30013 for cp as these differences are negative they suggest that employment income is lower for people with disability than for nondisabled people controlling for age and sex each of these differences were significant at a 1 level housing figure 4 shows housing outcomes including the estimated percentage of individuals living in corehousing need the estimated percentage of individuals living in housing in need of repair and the estimated percentage of individuals who are household maintainers by category of disability briefly corehousing need refers to housing that fails to meet standards for adequacy suitability and affordability and a household maintainer refers to someone who is entirely or in part responsible for household payments people with dd were more likely than nondisabled people to be in core housing need more likely to be in housing in need of repair and less likely to be a home maintainer compared to ad people with dd were more likely to be in core housing need and less likely to be a homemaintainer results were similar between people with asd and cp counterintuitively data from the 2017 csd suggests that people with ad are more likely to be homemaintainers than nondisabled people we hypothesized that this discrepancy may be driven by age and sex differences between these groups we base this hypothesis on the fact that age and sex can impact income and a barrier to housing for persons with disability in canada is a lack of affordability consequently we controlled for these variables using logistic regression we found or for dd of 0392 for ad of 0924 asd 0291 and for cp of 0669 as these ors are less than one they suggest that the probability of being a homemaintainer is lower for people with disability than for nondisabled people controlling for the impact of age and sex each of these ors were significant at a level of at least 2 with exception of cp which did not meet standard thresholds for significance after controlling for age and sex people with ad were less likely to be homemaintainers than nondisabled people in line with expectations supports for people with disability figure 5 shows estimates of who provides care for people with disability by category of disability for dd 520 of caregivers were family members the individual was living with 287 were family members the individual was not living with 163 were friends or neighbors 154 was a paid organization and 126 was an unpaid organization for all categories of disability the most common caregivers were family members benefit programs targeted at people with disability are one of the main ways in which governments attempt to address disparities for groups with disability figure 6 shows the estimated percentage of people with dd and ad who report being the beneficiary of a provincial disability support program by category of disability for dd the lowest percentage of people receiving provincial benefits was in newfoundland and labrador at 64 and the highest was in ontario at 491 for all provinces the percentage of people with dd receiving provincial benefits was higher than that for ad asd and cp were not included in fig 6 because of suppressed data due to both small sample size and high variability in addition to provincial benefits the federal government offers the registered disability savings plan this program serves as a tax deduction for people with disability however uptake of this benefit is minimal at approximately 02 for people with ad dd asd and cp were not reported because of suppressed data due to both small sample size and high variability discussion we are impacted by the inability to secure our sons future we are his sole social circle we are his financial backers we are his transportation we are his life my fears keep me awake at night if we dont have something in place a plan a program a support network what will happen to my son when im gone institutionalized neglected or worse homeless with no love or supports i need peace of mind and he needs a future parent statement for the canadian senate standing committee 2018 the aforementioned quote serves as a testament to the realities faced by people with dd and their families situations such as this are a reminder as to the need for inclusivity and provide context for the outcomes presented in this study our findings suggests that people with dd in canada experience lower educational attainment have poorer labor market outcomes and have poorer housing situations than nondisabled people compared to the general canadian public people with dd are 41 times less likely to finish high school 21 times less likely to finish postsecondary education 18 times less likely to participate in the labor force 24 times less likely to be employed 27 times more likely to live in inadequate housing and earn on average 32952 lessyear in total income these findings are largely in line with analyses of the 2012 csd however direct temporal comparisons cannot be made between surveys as the process used to identify respondents differed with respect to the demographics of people with disability the younger average age of people with asd identified in the present study is consistent with a recent trend of increased asd diagnoses estimates by the center for disease control suggest that autism prevalence increased approximately 25 times between 2000 and 2014 in the united states furthermore higher rates of asd diagnoses in males is in line with known trends in asd with respect to geography only 71 of people with cp live in rural areas possibly indicating a move to an urban center given the need for an accessibly built environment the lower rates of disability in northern regions identified in the present study is possibly explained by a lack of diagnostic capacity research suggests that people living in northern regions lack access to healthcare this lack of access may be resulting in less diagnostic capacity for dd and as a result fewer diagnoses education is crucial to improved career prospects and life outcomes regardless of disability status however compared to the general canadian public our findings suggest that people with dd are 41 times less likely to finish high school and 21 times less likely to finish postsecondary education this is consistent with findings in the united states suggesting that people with intellectual disabilities have the lowest rate of postsecondary enrollment of any group with disability at 287 and enrolment drops to just 67 when considering four year college programs an important distinction regarding high school completion rates in groups with disability is between those who dropout because of a lack of supports versus those who age out without meeting the academic standards for a high school diploma individuals who age out without meeting the necessary academic standards often receive a certificate of completion which is not equivalent to a high school diploma previous research in canada has suggested that 182 of children with severe or very severe disability will dropout prior to completing highschool low rates of postsecondary completion could be a potential driver of the comparatively poor labor force outcomes for people with dd our findings suggest that people with dd are 18 times less likely to participate in the labor force 24 times less likely to be employed and earn on average 32952 lessyear in total income relative to nondisabled people this is unsurprising in light of previous research suggesting that postsecondary education increases the odds of successful employment for people with dd and increases the likelihood of working more hours and earning higher wages income disparities for people with dd are striking and our findings suggest that government benefit programs are not adequately meeting the needs of people with dd this is most prominently demonstrated by the difference in total income between people with dd and nondisabled people nondisabled people earn on average three times that of people with dd further compounding this issue is the inability of people with dd to access benefits and services only 101491 of those with dd surveyed were beneficiaries of provincial benefit programs for people with disability depending on province and only 02 of people with ad were using the rdsp this low uptake may suggest that programs are not appropriately targeted to people with disability either being overly burdensome and complicated or administered through the tax system many people with dd do not file taxes e e e e e f e e e e e x e f the cumulative effect of low income and inadequate access to benefit programs has likely contributed to the high number of people with dd living in poverty 282 when measured by the mbm this is likely an understatement as the mbm does adequately account for costs incurred by people with disability specific to their condition that nondisabled people would not have to pay people with dd were also more likely to live in inadequate housing and more likely to live in housing in need of repair compared to nondisabled people improving access to programs benefits and services represents an essential step in improving outcomes for people with dd the industries that employed people with dd are similar to those for ad and the general canadian public based on statistics canada data the top industries of employment in canada for 2017 by number of employees were healthcare and social assistance retail trade manufacturing professional scientific technical services and construction it is important to point out that there are differences in ordering in the industries of employment between people with dd and the general canadian population for example accommodations food services is the third most common industry of employment for people with dd but only the seventh most common for the general canadian public our findings suggest that family members are the most common caregivers for adults with dd these findings potentially speak to the degree to which unpaid caregiving occurs in canada it has been estimated that there are 78 million canadians who care for either a family member or friend with disability this caregiving which tends to be disproportionately done by women likely has a substantial impact on canadas economy as previous research suggests that caregiving affects the labor market decisions and productivity of caregivers the barriers reported in the csd can provide guidance on areas for policymakers to focus their efforts in addressing disparities commonly reported barriers to employment include a fear of losing disability supports a lack of appropriate job training and a lack of success during previous attempts to find employment based on these barriers programs that incentivize companies to hire people with dd less aggressive claw backs of benefits for people with dd who enter the workforce and additional training programs for people with dd could represent targeted policy approaches to improve outcomes it is important to point out that policy efforts cannot be made in the absence of people with disability for disability related policy to be effective in achieving its objective it is important that people with disability be central in the policymaking process in almost all of the comparative analysis presented in the present study that included people with cp individuals with cp had comparatively worse outcomes than the general canadian population or people with ad these findings are largely in line with existing research on employment education and standard of living outcomes for people with cp previous research has suggested that individuals with cp are subject to a compounding effect whereby lower educational attainment translates into lower employment outcomes and income huang et al suggest targeted educational and vocational supports are required for people with cp these supports are particularly important during times of transition such as when youth first enter the workforce or begin independent living there are limitations associated with data collected from the 2017 csd the csd does not capture data for people younger than 15 living on first nations reserves living in collective dwellings such as senior facilities assisted living facilities correctional facilities hospitals military bases or for the homeless as a result the csd likely missed a substantial portion of people with disability furthermore beyond the 10 prespecified disability types respondents needed to specify additional conditions to be categorized in these groups as a result the survey likely missed a portion of people with asd and cp who did not report these disabilities given the limitations of the 2017 csd we speculate that the sample represents a relatively high functioning portion of canadians with disability given this survey is administered as an online questionnaire there are potential sampling selection and representability issues to mitigate these statistics canada identified participants who would be less likely to access the online survey and contacted these individuals if they did not respond to the 2017 csd to offer alternative interview formats this study describes the status of people with dd in canada prior to the introduction of accessibility legislation 1 3 focusing on employment education income housing caregivers and use of government benefits findings indicate that there exists substantial disparity between people with dd and the general canadian public and a need for reducing barriers in communities schools and workplaces to close these gaps legislation guaranteeing equal participation at the provincial level for people with disability will be beneficial though federal laws exist only manitoba nova scotia and ontario currently have accessibility legislation furthermore merely adopting these policies is not sufficient it is important that these laws are enforced secondly barriers to accessing supports need to be removed wherever possible for example using tax credits as a mechanism to support people with disability may not be a useful approach finally workplace and educational accommodations need to be made available for people who need them this study found that some of the most commonly required work and educational accommodationssupports were the least commonly provided author contributions pb provided report writting and stastical analysis cwms provided report writting statistical analysis and knowledge of disability policy jdz provided report writting knowledge of disability policy and conceived of the study compliance with ethical standards conflict of interest the authors report no conflicts of interest ethical approval conjoint faculties research ethics board review through the university of calgary was not required as this research relied exclusively on secondary use of anonymous information open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit iveco mmons orglicen sesby40 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this study assessed needs and outcomes for people with developmental disability dd to understand the socioeconomic status of this group prior to implementation of the accessible canada act in june 2019 the 2017 canadian survey on disability csd was used to analyze data for a sample of individuals with selfreported disability data related to employment education income housing caregivers and use of government benefits is reported compared to the general canadian public persons with dd are less likely to finish highschool or postsecondary education participate in the labor force or be employed and earn on average lessyear in total income to align with recent accessibility legislation significant progress is needed to address disparities for people with dd

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introduction in the past decade social media have become pervasive information systems that penetrate many areas of our lives in 2020 social media platforms such as instagram facebook twitter or tiktok have been actively used by 381 billion users globally and this number is still growing users generate content seek information and interact on social media platforms the resulting data presents valuable opportunities for companies governments and researchers to understand and interact with users the process of collecting monitoring analysing summarising and visualising social media data is referred to as social media analytics which has evolved into a recognised research methodology in the is discipline and beyond at present it is applied in various fields such as disaster response political communication or marketing while sma poses a plethora of potential benefits it is also subject of an ethical debate for example the collection of personal data often without informed consent raises questions about the privacy rights of users the publicness of data stemming from social media platforms and whether agreeing to the terms and conditions of the platform is sufficient for using the data in research these and other ethical issues in the context of social media data have not been sufficiently addressed in is research with the growing impact and utilisation of social media data respecting ethical considerations in the sma process becomes increasingly critical this is not only reflected in different calls for more research in this domain but also in recently established legal requirements such as the general data protection regulation and rigorous ethical assessment requirements on sides of financing boards and scientific journals different communities such as the association of internet researchers the institute of electrical and electronics engineers and the association of computing machinery have published ethical guidelines which address separate elements of sma research for example the internet research ethics 30 however these fail to provide sufficient practical guidance for researchers within the specified sma research process and navigating this diverse landscape of multidisciplinary patchwork remains challenging for sma researchers ethical guidelines can be complex too ambiguous for certain research projects and their consideration timeconsuming which might explain their insufficient integration in sma practices therefore in this paper we explore the following research question rq how can ethical conduct be incorporated in the social media analytics process to answer this question we follow the design science research approach to develop an extended version of an acquainted sma framework which includes ethical reflections that iteratively attach to the process of conducting sma research specifically we adapt the threecycle view of dsr to establish our knowledge base and draft an initial version of the artefact we turn to the state of the art of sma research and existing ethical guidelines in adjacent fields followed by a description of the application environment subsequently we refine the framework based on twelve expert interviews with leading scholars in the fields of sma and digital ethics to evaluate the applicability of the final framework we conducted two focus group discussions with sma researchers and collected feedback from the initial round of experts senior sma researchers as well as members of university ethics boards our study attempts to make both theoretical and practical contributions and is thus an example of applied ethics which seeks to give guidance on how sma researchers can act normatively right the common values and norms of the specific group of sma researchers forms the core interest of this study first we provide them with a refined framework of sma research that incorporates ethical reflections at every stage of the research process which closes the gap between practical implementation of sma measures and theoretical ethical considerations which can create implications both on an individual and a societal level as a result our research mediates between two disjoined perspectives on sma that is application and ethics and equips sma researchers with an applicable framework to facilitate ethical conduct throughout the sma process according to stahl normative is research deals with four different areas moral intuition explicit morality ethical theory and metaethical reflections based on this classification our research is located at the explicit morality level this means that it goes beyond individual moral intuition which is the direct personal reaction if something is the right or wrong but instead defines the agreed moral values of sma researchers and applies them to the different steps of their research process this step forms the basis for the formation of ethical theories and metaethical reflections which not only ask what action is right but why a certain action is right and how it can be interpreted in the context of different ethical schools of thought the remainder of the paper is structured as follows first we give an insight into the methodology of the study followed by the rigor cycle which is based on the literature on sma in is and existing ethical guidelines subsequently we present the rigor cycle which explicates the application environment of the artefact this will be followed by the artefact description and the explanation of our evaluation methods and results conclusively we present the final framework and discuss its implications limitations and provide suggestions for further research methodology the methodological basis of this study is grounded in the dsr approach popularised by hevner it constitutes a paradigm that looks for innovative solutions of problems through the design of artefacts which can be of different nature as depicted in figure 1 the approach includes three research cycles the rigor the relevance and the design cycle the first cycle of dsr the rigor cycle gives an overview of the existing knowledge base including the most relevant scientific theories and models the stateoftheart in the field and the description of existing artefacts and processes the sma framework by stieglitz et al forms our knowledge base as it thoroughly summarizes the steps of the sma research process further we analysed the existing literature and guidelines for ethical research focussing on those relevant to sma and big data analytics the relevance cycle which will be addressed in the fourth section provides the context of the dsr project by analysing the environment and formulates the main problem and resulting needs in addition it provides the criteria for the evaluation of the final artefact the third and internal cycle of dsr is the design cycle it is driven by the input from the rigor and relevance cycle and aims at designing building and evaluating the artefact overall we turn to ethics by design to provide us with design principles for the artefact as it suggests accompanying the entire research lifecycle with ethical questions and the anticipation of future implications specifically our design cycle included four steps 1 developing a first version of the framework based on the input from the rigor and relevance cycle 2 the substantive evaluation of the first version with expert interviews with ethicists and sma researchers an 3 evaluation of the second version with two focus groups of sma researchers focusing on the two acceptance criteria and an 4 evaluation of the third version of the artefact based on feedback from researchers applying the framework to a recent sma research project 3 rigor cycle literature review social media analytics in information systems research the notion of sma refers to an interdisciplinary approach to social data analysis that primarily takes a methodical standpoint it combines a set of datadriven analysis techniques including the collection analysis and visualisation of social media data incorporating the sma approach adds significant innovative strength to the discipline of is as it broadens data foundations provides swift analysis of realworld phenomena and allows a higherlevel perspective on collective online behaviour in recent years we could observe is literature spawning resourceful studies using sma in various fields such as disaster response social movements or political communication specifically sma encompasses the tracking and scientific utilisation of large social media datasets the approach envelopes a set of suitable methods to systematically analyse social media data stieglitz et al divided this process in the work stages of discovery tracking preparation and analysis figure 2 provides an overview of the sma framework figure 2 social media analytics framework adapted from stieglitz et al in this paper we build on this sma framework because it provides researchers with methodical guidelines to undergo an applicationdriven replicable process of deploying social media as a data source for empirical research the framework was extended to cover challenges in event and topic detection setting up a software architecture and data visualisation and quality it constitutes a seminal aid to orientation for novice and experienced researchers which as of this writing is mirrored in the combined citation count of 714 between the original version and its first extension we carefully reviewed other sma frameworks but found that they are either contextspecific eg enterprises or focus on certain methodical approaches eg machine learning more recently scholars have advanced the field of sma by testing the possibilities of data exploration and establishing social media as a viable data source for is research however aside from its methodical value and high degree of applicability the sma framework by stieglitz et al or other related literature have not yet sufficiently addressed ethics as an integral part of the sma research process ethical issues of social media analytics along with the applicationoriented benefits of sma several ethical challenges emerge in the research process for example related to the privacy of social media users and identifying acceptable levels of intrusion nonconsensual experiments and accounting for potential biases recent publications in is highlight the shortage and importance of ethical considerations in big data analysis and sma and called for more research in this domain thereby data scientists are considered to play an important role as they translate data into knowledge and actionable insights and function as change agents however prevalent practical frameworks describing the application of sma do not broach the issue of ethics concurrently existing ethical guidelines in this domain insufficiently capture the ethical challenges that emerge at different stages of the sma research process 2020 a highlevel overview of their codes of conduct and guidelines is provided in table 1 each of these guidelines or codes of conduct covers some aspects which are relevant to sma researchers such as data privacy guidelines focus association of computing machinery code of ethics and professional conduct principles and responsibilities to inspire and guide ethical conduct of all computing professionals association of internet researchers ethical decisionmaking and internet research recommendations from the aoir ethics working committee recommendations designed to support and inform those responsible for making decisions about the ethics of internet research association for information systems code of research conduct requirements recommendations and advice for conducting research and publishing in is ieee code of ethics principles of ethical and professional conduct in the context of emerging technologies table 1 overview of guidelines and codes of conduct applicable to sma the broad emergence of ethics guidelines indicates a high demand for practical guidance which brings together theoretically derived ethical concerns but also the everyday experience of researchers and practitioners besides handson guidance additional meta studies on the role of ethics guidelines also address the guidelines shortcomings due to the abundance of guidelines and research on ethical questions sma researchers face the challenge to identify those ethical questions which are relevant for their specific research process to design our artefact we draw on the meta concept of ethics by design which understands ethical research not as a binary decision before the start of a research project but rather as a continuous iterative process ethics by design which evolved from the concept of privacy by design suggests an accompaniment of the research lifecycle by asking ethical questions and anticipating its implications for society even though an emergence of tentative research and guidelines related to the field of sma can be observed however guidance that focuses on the specificities of the sma research process has not been provided so far to address this shortcoming our paper will proceed with the specific challenges and relevance cycle institutional challenges of ethical sma research the purpose of this section is to highlight involved actors organizational and technological structures as well as problems and opportunities of our research this helps to determine the application context of the artefact and requirements that need to be considered the application environment of this study is academia the potential users of the artefact which aims to provide ethical guidance throughout the entire sma research process are researchers of different disciplines experience levels ranging from undergraduate students to full professors resulting in discipline disparities sma is applied by researchers from social sciences and computer sciences such as information systems however each discipline approaches social media with different research questions and varying methods which evoke distinct ethical problems consequently the way sma is applied and understood may significantly differ while researchers from computational sciences are equipped with sophisticated methods for the analysis of social media data they are often less concerned with methodological underpinnings and theoretical models which researchers from social science employ to make sense out of social media data academia has an international orientation despite cultural differences and contrasting trends of serving national priorities and operating in an international setting while maintaining its core objectives of teaching research and communitybusiness partnerships this cultural pluralism in academia may lead to ethical pluralism which affects the ethical choices made in the sma research process the acceptance of scientific quality standards oftentimes collides with the high pressure to succeed and publish in academia colloquially known as the publish or perish culture this tension sparks a lot of ethical questions regarding the validity of sma research and the implications of research for academia the industry and society additionally academia is witnessing an ongoing discourse about openaccess culture involving an enhancement of research data management to benefit the community and the individual researcher although improved collaboration and knowledge sharing may entail benefits and opportunities from an ethical point of view it also sparks issues regarding the privacy protection of users in social media datasets which keeps sma researchers stuck in a dilemma the technological infrastructures available to sma researchers differ tremendously as they highly depend on the financial resources of each institution and on the technology access in the respective country generally however academia can be considered a digitised area of work the target group of this study researchers who conduct sma work with their computer and complete most of their work digitally their media competence may vary depending on their area of expertise which may result in different abilities to evaluate the ethical hurdles linked to the technological components of sma such as machine learning algorithms supporting the data analysis additionally there are regulatory differences for example between international academic partners exemplified by authorities creating a disparity in ensuring compliance with certain ethical standards in 2018 the gdpr a binding law in the european union converted ethical challenges especially regarding the protection of data and research subjects into hard law the gdpr lately influenced the debate on research ethics and is relevant for all entities which deal with data collection analysis and storage in countries of the european union from these and the arguments presented prior in the rigor cycle we derive two acceptance criteria which should be met in the evaluation of the artefact australasian 1 awareness for ethics the artefact encourages or extends ethical reflection throughout the sma research process for a diverse group of researchers 2 applicability of the artefact the artefact is a useful tool for sma researchers based on the reviewed knowledge base and the identified application environment and acceptance criteria we derive the initial version of the artefact in the first design cycle design cycle artefact description the initial artefact was composed of the sma framework and five additional ethical reflection stages highlighting relevant ethical considerations in each step of the sma process these stages were derived from ethical guidelines and scholarship originating in research fields referential to sma the first version of the artefact is depicted in figure 3 figure 3 initial artefact with adaptations to the framework highlighted if the initial idea or research design is unethical following ethics guidelines later does not solve the initial issue thus the meta reflection stage covers necessary theoretical and ethical overtones of sma research including initial biases avoiding harm doing good legal considerations power issues transparency cultural dimension and ethical questions of your field which accompany and guide the entire research process initial biases are based on the need to reflect on personal and technical biases that relate to ones sociodemographic or cultural background or the expected results what are my personal expectations of my research and how they influence the research design who might be missing or silent in the proposed research design overall researchers should strive to magnify the public good thus the subcategory avoiding harm doing good was included to encourage researchers to reflect on who benefits from their research i my discipline or the society as a whole how could possible harm be avoided and how can the researcher give something back to the researched communities ethics and law are highly interwoven hence the subcategory of legal considerations was added for example many ethical issues surrounding individual data rights are covered by the gdpr which is binding law in the european union hence sma researchers should be aware of the legal frameworks which apply to their research and potentially discuss these with collaborators from other judicial areas besides binding laws sma researchers are confronted with the terms and conditions of the social media platforms these often restrict data collection and thereby limit possible research designs and outcomes of sma this tension is referred to as power issues and researchers should reflect on how these have shaped the research design other power issues can occur between thirdparty funding institutions or between researchers and research subjects especially when researching more vulnerable groups the value of transparency is very prevalent in most ethics guidelines and is becoming increasingly important in research thereby a challenging question for sma researchers is how much access into social media datasets is acceptable without violating individual privacy sma researchers should consider how they can operationalise transparency in their research for example by obtaining strong informed consent agreements the importance of the socalled cultural dimension for ethical reflection has been stressed by the aoir ever since conducting internet research especially in social media involves crossing cultural boundaries norms practices and beliefs individual versus relational concepts of selfhood cause the necessity for individual or more relational consents internet research ethics is grown from the local source meaning that the ethical vocabulary comes from the traditional and intellectual source of the culture in which a particular researcher is working lastly each field of research follows its own code of conduct with the subcategory ethical questions of your field we aim to encourage and provide room for an open and ongoing dialogue with the ethical guidelines of ones faculty or institute the tracking reflection stage covers informed consent issues related to the venue of research privacy autonomy anonymity discrimination and data minimisation while research has shown that informed consent might be difficult to obtain in big data research before data tracking the question remains of how to inform subjects about their data being used for research purposes how can research be conducted so that autonomy of the user is protected1 the subcategory venue is derived from the necessity of contextsensitive research and refers to the characteristics of the researched social media platform and subjects specifically the type and sensitivity of the communities actions and interactions under study but also the expectations of the individuals evoked by the platform for example despite having signed the terms and conditions users might not expect that data from a seemingly more private venue eg a telegram channel can be accessed by third parties privacy too is a dominant norm in ethics guidelines and refers to the right to control data about oneself thereby a privacy paradox can be observed people share a lot of personal information online despite valuing privacy which might be due to a lack of awareness that this information is entirely public moreover classifying individuals into ad hoc groups based on social media data to inform algorithmic decisionmaking might lead to violations of group privacy which steps can be taken by sma researchers to protect individual and group privacy protecting users autonomy anonymity requires researchers to reflect on whether applied social media interventions or analysis methods could be manipulative or invasive a negative example which might have harmed research subjects is an experiment by facebook which altered the timeline to show more positivenegative content to users to investigate emotional contagion further ethical issues might arise if analysis methods are used to infer sensitive information or make predictions about individuals based on social media data for example whether someone is likely to become depressed social media data is rarely representative of the researched community and derived insights might lead to discrimination of individuals or groups sma researchers should reflect on who will be represented in the tracked data and how that might influence possible results and the generalisability of their research lastly data minimisation is not only a principle of the gdpr but might also reduce ethical risks while big data sets are crucial for some types of analyses researchers should try to minimise collected data for example by using specific timeframes and keywords or sharing and reusing data the preparation reflection stage entails data cleaning biases and unintended insights social media data can be of low quality or noisy for example due to colloquial language typos and emoticons thus unstructured data such as tweets often require extensive data cleaning prior to analysis the cleaning decisions typically reflect the researchers value judgements of the data which can influence the subsequent analysis and results thus researchers should reflect on their motivation and expectations when cleaning social media data and consider its impact for example how does removing data affect obtained results or minority representation biases during the preparation phase refer to incomplete or inherently biased data sets provided by social media platforms and other data providers which procedures are employed by the platform are these transparently reported and was the obtained data set examined for inherent biases conducting big data driven research such as sma can lead to unintended insights about user which were not of primary interest to the researcher if these insights touch on sensitive areas researchers might have a responsibility to act for example by informing authorities to avoid harm the method reflection stage involves the aspects validity and algorithms as in every research project the validity of applied sma methods should be ensured thus methods should not be chosen habitually but selected based on their ability to accurately measure the aspects relevant to the research question the use of algorithms for example in the form of supervised or unsupervised machine learning approaches to identify patterns or clusters in the data set entails several ethical hurdles major concerns involve possible algorithmic biases which are closely linked to biases in the training data and discrimination as well as the black box problem which is related to the question of algorithmic explainability accountability and traceability do i understand the functionality of the algorithm and can i explain the results who is responsible for potential harm resulting from the use of this algorithm am i aware of the limitations such as the shortcomings of natural language processing approaches for detecting sarcasm and irony which can influence the results of a sentiment analysis the publication reflection stage comprises the ethical considerations informed consent sharing storing of data gender diversity cultural dimensions and future implications as already mentioned in the tracking reflection informed consent is essential for protecting the privacy of research subjects in sma if informed consent cannot be obtained prior to data tracking another approach is to ask for informed consent of those subjects whose accounts or content are analysed or mentioned in the paper prior to publication studies show that users are only slightly concerned regarding the use of their social media data for academic research but they do expect to be asked for their consent when publishing sma research sharing storing of data becomes relevant as sma researchers need to evaluate how to store and share data while complying with legal and ethical considerations while research grant providers often require an open access publishing of results and data sets and researchers increasingly see the advantages of open data this principle collides with the terms and conditions of social media platforms like twitter and might lead to reidentification of research subjects furthermore sma researchers should reflect on gender diversity and cultural dimensions of their analysis and results prior to publication the sma researcher should be aware that social media platforms often do only display a minor part of society which not always include diverse gender and cultural backgrounds thus findings are often not generalizable to society and sma researchers should consider and report the limitations of their data and analysis lastly the future implications refer to possible consequences of sma research this point is closely related to the idea of avoiding harm doing good in the meta reflection stage what effect might my analysis have on the individuals and groups involved in the study and on society the awareness that my research has future implications is tied to the idea of rri and the approach of ethics by design but is also an integral part of ethical guidelines for example reflected in the principles of the acm 6 design cycle evaluation methods round 1 expert interviews the first version of the framework was evaluated with twelve interviews conducted with experts in digital ethics and sma research on the professorial level the selection criteria included expertise in the use of sma or expertise in related ethical questions and diversity in terms of cultural background and gender table 2 overview of the interviewed experts the semistructured interviews took place via skype zoom or google hangouts between may and august 2020 all participants provided their informed consent to record and analyse their interviews the data was analysed and stored within one research institution the interview guidelines which were slightly adapted for sma researchers and ethicists respectively consisted of six question blocks the introductory questions aimed at evaluating the expertise and focus of the interviewees the question blocks twofive asked for the ethical challenges and implications of each phase of the sma research process then the experts evaluated the extended framework which was provided one week in advance the experts were encouraged to add ethical implications or to propose changes lastly the interviewees were asked for general comments and if the framework would be helpful for them and their research the transcription was conducted with the tool maxqda following kuckartz transcription guidelines for computeraided content analysis the qualitative content analysis was conducted according to the rules of mayring the category system was based on deductive codes which were derived from the literature for example informed consent and privacy are deductive codes one category derived from the interview input for example is protecting the researcher to ensure the reliability of the coding process one out of twelve interviews was coded separately by two coders cohens κ coefficient of 08 confirmed the agreement between the coders to be substantial round 2 focus groups to evaluate the artefact with regards to the defined acceptance criteria of awareness for ethics and applicability of the artefact two confirmatory focus group discussions were conducted according to tremblay et al focus groups can be used to refine and evaluate artefacts in dsr focus groups were chosen as the evaluation method because they allow the evaluation of the artefact in a realistic scenario and offer very rich qualitative interaction data morgan defines four to twelve participants as suitable to keep the level of interaction high and to prevent social loafing we included four participants in each group corresponding to the application environment of the artefact the participants were selected based on their experience with sma and their general level of research expertise as the artefact should effectively support researchers from different experience levels the focus groups included phd candidates and senior researchers table 3 overview of the focus group participants and their prescribed pseudonyms all participants provided their informed consent to record and analyse the discussion prior to the two confirmatory focus groups a pilot focus group with six student assistants with experience in research and sma was conducted via google hangouts to test and refine the guidelines and the procedure the discussion was structured as follows after welcoming the participants and summarising the contents of the discussion all participants were asked to introduce themselves briefly to establish a basic familiarity within the group afterwards the following task was presented the group was asked to imagine being a research team aiming to develop a research design to investigate the different actors who are involved in the discussion about covid19 on social media then the group was invited to a virtual google jamboard where they were asked to write down a research design and the connected ethical considerations as an inspiration for the different steps the sma framework by stieglitz et al was given due to the challenging task of designing a research project in a team and the limited time it was unlikely that participants would touch on all relevant ethical considerations included in the framework in the first round of discussion therefore as an indication of the perceived importance and completeness of ethical considerations in the developed research design we asked each participant separately to rate their agreement to the following two statements on a 5point likert scale ethical considerations played an important role in the development of the research design and i am confident that we discussed all ethical considerations that are relevant for sma research to i fully agree afterwards the extended sma framework was explained by the moderator participants were then asked to discuss if and how they would refine their research design based on the extended sma framework after this discussion another questionnaire was filled out individually by the participants to avoid a social desirability bias it included five questions which aimed at evaluating the applicability of the framework in the final 15 minutes the participants were asked to jointly discuss the framework with a special focus on the evaluation criteria awareness for ethics and applicability of the artefact the guidelines for the focus group discussions are included in the appendix b we consider the first evaluation criterion to be fulfilled if the extended framework stimulates and extends the awareness of ethical considerations in the development of an sma research design we operationalised this by 1 comparing the ethical considerations mentioned in the first discussion supported by the original sma framework with those mentioned in the second round of discussion supported by the proposed extended framework and by 2 analysing statements on the extended framework during the discussion which support or challenge its capacity to stimulate and extend ethical awareness we consider the second evaluation criterion applicability of the artefact to be met if the extended framework is perceived as a useful and applicable tool by sma researchers we operationalised this criterion by 1 analysing the comments on and interactions with the extended framework during the discussion 2 the direct feedback provided on the extended framework at the end of the focus group discussion and 3 the private questionnaire ratings on the five statements assessing the applicability of the framework the analysis of the focus group data was conducted according to the described approach for the analysis of focus group data in is research by nili et al as this focus group was conducted virtually nonverbal interaction data which requires an interpretation of movements and gestures in interaction with other participants was not considered instead we focused on the content and verbal interaction data round 3 survey of initial experts senior sma researchers and ethics boards in the final evaluation a survey was conducted among six ethics board members to collect reasons for criticizing or rejecting sma studies and consulted sources for ethical evaluation this was done to ensure that all mentioned aspects are covered by the final artefact we chose this approach over a detailed evaluation of the ethical issues in the artefact as it covers all phases of the sma process in a smallstep manner and exceeds the scope of work of the ethics boards which only make onetime decisions before the start of a study thus a second survey was conducted to evaluate the framework itself involving four experts from the first evaluation round as well as seven additional sma researchers to do justice to the circular nature of dsr and to test the artefact in a realistic scenario interview results the aim of the expert interviews was to evaluate the completeness of the first prototype of the artefact the results of the interviews have led to several additions and changes which will be outlined in the following the meta reflection phase was moved prior to the research domain in the framework to emphasise the overarching nature of these questions regardless of the specific research project additionally the subcategory of avoiding harm doing good was changed to general orientation of research and orientation towards the common good the former includes questions related to the beneficiaries of the research and the gutfeeling of the researcher about the research aim the latter was included to account for research which might have to violate certain ethical principles to serve the common good to emphasise that the tracking reflection should be done prior to data tracking it was renamed to pretracking reflection furthermore data gathering was added to point to the ethical implications of alternative or complementary data sources such as purchased datasets or existing datasets and their impact on the analysis and results further the interviewees highlighted the complexity of informed consent for example in terms of cultural diversity and feasibility due to low number of replies on social media and that there is no other sensible way to reach these people overall interviewees often regarded consent more relevant for small data sets private accounts casespecific analyses than for mass data public accounts and aggregated analyses thus this distinction was added the related concern of reidentification of individuals after publication was added to the publication reflection due to different national legislations sharing storing was added as researchers might have to agree on gdprcompliant services and procedures also when sharing data sets r06 highlighted that if you merge it your data with my data i might now suddenly be able to identify your subjects and there is no fault of yours other than the fact that you shared it with me therefore the aspect of data merging was added to the preparation reflection in the preparation reflection before analysing the data the protection of the researcher should be considered r03 mentioned we have to offer researchers more and more sophisticated ways of protecting their identity online so that they dont become a target but also analysing hate speech or misinformation on social media can be emotional stress lastly r12 emphasised that you have to make value judgements on the data before you process the data before you analyse the data … i think its important to understand that statistical is also based on value judgements … whether you choose a particular confidence level of 5 or 1 or 5 will determine what comes out as significant in the end and thats not a natural occurrence that is a value judgement that is driven by something and has consequences for whatever you can say in the end hence we added that researchers should reflect on the limitations of their data and analysis and make those explicit in the method reflection four aspects were added first the potential exposure of sensitive attributes or relationships of social media users for example when conducting social network analysis biases were added to raise questions about unequal representation in the data and the generalisability of the results furthermore aggregated analyses might not harm individuals but the derived insights could have harmful implications for groups of people to address these ethical concerns researchers should examine whether their results are supported by other data in the last reflection phase the publication reflection gender and cultural aspects were merged in the more inclusive promoting diversity aspect asking researchers to discuss diversity in their studies and to reflect their own socioeconomic cultural and personal background lastly giving back was added to inspire researchers to think about ways of compensating participants and sharing research benefits or insights with them focus group results the confirmatory focus group evaluation of the second version of the framework which resulted from the expert interviews targeted two evaluation criteria awareness for ethics and applicability of the artefact table 5 provides a summary of the supporting and opposing or challenging evidence for the two evaluation criteria in the first survey of fg1 one reply is missing due to technical issues in fg1 while participants perceived ethical considerations to have played a moderately important role the perceived completeness of discussed ethical considerations was very low hence possibly the participants could have discussed more ethical hurdles when given more time this limits the insights for the first evaluation criterion derived from the prepost analysis of discussed ethical considerations in fg1 in fg2 however the perceived importance and completeness was medium to high suggesting that the additional ethical reflection in the second round for example related to power issues can be assigned more clearly to the guidance provided by the extended framework moreover the interactions and statements during the further feedback on the framework addressed the terminology the need for a contact person for ethical guidance and the challenge of balancing ethical considerations and research interests thus the focus group evaluation highlighted that for the extended sma framework to effectively support ethical reflection and be useful for sma researchers the ethical issues in the framework require additional explanatory material to address this feedback we compiled a manual including a short description of each issue relevant sources and a list of reflective questions to complement the extended sma framework thus the third version of the artefact consists of the extended sma framework and the supplementary material both were once again evaluated regarding the acceptance criteria results of the final evaluation in the final evaluation round the sma researchers applied the artefact to a variety of sma topics and methodological approaches for example to studies with a focus on enterprises or the analysis of infodemics and popcultural phenomena with qualitative and quantitative methods regarding ethical awareness twelve of the 34 ethical issues each provided additional food for thought for at least six of the sma researchers for each of the remaining 22 ethical issues at least one of the sma researchers indicated that it stimulated ethical reflection thereby the ethical issue common good of the meta reflection stage was selected most frequently and discussed in the open feedback as well for example r18 asked himself in how far it would be unethical to do research which has no contribution to the common good further r5 emphasized that the focus of ones own study influences the individual importance of various subaspects which makes every ethical evaluation an individual process as all participants were senior researchers with extensive experience several noted that the had already implicitly taken many points into consideration sometimes due to special industry standards of their application environment yet the participants shared the positive impression that the framework would support them in planning and conducting sma studies and provides additional value to existing guidelines the easiness to understand the framework was rated slightly lower yet all participants moderately to strongly agreed that they would apply the framework in their research and recommend it to their phds and students more divided was the opinion of the participants if the framework reduced the methodological quality of their work while nine researchers could not identify any negative impact two were sure that there was a negative impact on their methodological quality the support by the initial list of reflective questions was rated as high the easiness to understand the list of initial reflection questions was rated a bit higher than the overall framework similar to the overall framework the participants saw added value of the initial reflection questions to existing guidelines all participants moderately to strongly agreed that they would apply the list of reflection questions in their research and that they would recommend using the reflective questions to their phds and students the survey of six ethics board members found that the main reasons ethics boards rejected research designs was due to privacyrelated issues which were not considered sufficiently by research teams respondents mentioned privacy as a generic term but also profiling reidentification anonymity and the legal issue of informed consent and gdpr furthermore the respondents mentioned neglected sensitivity of data planned manipulation of subjects and protection of the researcher from negative influences in the form of false news and violent scenes as points to be considered two other metathemes raised were the limitations of the openscience ideals in social media research due to legal boundaries and taking potential negative impacts of sma into consideration to guide their evaluation the respondents consulted different sources such as institutional bodies or articles books and existing guidelines such as legal considerations all agreed that additional guidance with a more specific handson approach is missing discussion the evaluation rounds involving two focus groups individual application of the framework to a realistic scenario and consultation of ethics boards supported both acceptance criteria indicating that the artefact provides a valuable addition to the environment of sma researchers specifically the extended sma framework and the accompanying reflective questions cover the crucial points for ethical approval of ethics boards from different cultures and regulatory environments and thus could help sma researchers to prepare better for such evaluations thereby the framework goes beyond the onetime evaluation of a study by providing specific guidance throughout the entire research process in the evaluation with a group of culturally and thematically diverse highly experienced sma researchers the artefact was perceived to stimulate ethical reflection the combination of the extended sma framework and the reflective questions were rated as highly applicable and useful for researchers with less experience in sma as well nevertheless the evaluation also highlighted certain challenges which need to be considered while applying the extended sma framework and which we will discuss in the following section one of these challenges concerns the interpretation of the ethical issues in each phase as a rule book that the researcher must follow and the wish for specific ethical best practices this perception points to a prevalent yet problematic tick the boxapproach to research ethics while ethical committees examine and approve research designs only prior to the start of the research project these approvals are often based on standardised criteria which does not do justice to the explorative character of sma due to the unique challenges of sma research such as quickly changing circumstances changing terms and conditions new features etc and the interdisciplinary nature of sma providing explicit rules to follow would likely fail to capture the reality of sma research thus by providing descriptions of possible ethical issues and reflective questions we aim to stimulate reflection yet not every aspect is equally relevant for every sma study especially given that sma research is also used in timepressing and societally highly relevant domains such as disaster response some ethical considerations might be neglectable in those cases however these ethical deliberations are complex and need to be evaluated on a casebycase basis hence similar to the ethics by design approach our study shows that sma research ethics require open reflection throughout the research process and iterative adjustments the extended sma framework in combination with the reflective questions embody these principles the optimal presentation of the framework is an area for future research based on the feedback from the interviews and focus groups we imagine an interactive website which allows users to gradually zoom in on the stage of the research process they are currently interested in to avoid the framework to be overwhelming moreover the website might incorporate ethical questions tailored to the users sma project such a website could also provide a platform for researchers to discuss research designs and best practice examples lastly it is noted that the different reflective questions are often interrelated or even overlapping for example the question of informed consent is always linked to the value of transparency which relates to the autonomy and privacy of the user between providing concrete questions tailored to sma processes without oversimplifying abstract ethical concepts is an ongoing challenge the artefact in its final form marks a first step towards providing muchneeded applicable ethical guidance for sma researchers and shall serve as a basis to ignite further discussions and subsequent research within the field on how to ethically approach sma it can be understood as research routed in explicit morality setting the foundation for deeper thoughts and a step towards ethical theory we encourage researchers to investigate additional methods and useful theory that supports the ethical reflection of sma researchers in the future including the mapping of additional maybe institutional or other hindrances to why ethics guidelines are accepted and used we are convinced that there will be a rich vein for further research also on the theoretical underpinnings of the design and usage of ethics guidelines in sma limitations and future research ethics and sma research are constantly evolving fields thus the presented framework can only be as good as the current knowledge base to succeed at providing sma researchers with practical guidance it will be necessary to regularly check and update the framework although the framework was evaluated with the help of twelve expert interviews two focus groups and applied by individual experts to a realistic scenario applying the framework in practice and over longer period will provide richer insights simultaneously the optimal presentation of the framework should be elaborated by testing the artefact in diverse cultural contexts the limitation that the authors all have a western european background can be overcome further it would be helpful to conduct a systematic literature review on the prevalent ethical topics in sma research to map the debate indicate the overlaps of different concepts and thus increase the applicability of those discourses to the research process conclusion to decide what is morally right or wrong in the research process can be a major challenge for sma researchers as they are confronted with an abundance of theoretical ethical debates dilemmas ethical guidelines and legislations the excessive demands a possible lack of sensitisation for ethical issues and high time pressure in academia can lead sma researchers to squander the chance to conduct more ethical research in this paper we present a framework for ethical sma research which assists researchers to reflect the ethical implications of their decisions throughout the entire sma research lifecycle the sma framework by stieglitz et al was chosen as a basis and was extended by five ethical reflection stages the meta pretracking preparation methodological and publication reflection the reflection stages provide researchers with thoughtprovoking impulses to ethically reflect their research design and implementation to better understand which questions might be relevant for their specific studies a list of additional descriptions and reflective questions is provided based on ethics by design principles the framework for ethical sma research can accompany researchers throughout the whole research lifecycle and thus can function as the practical guidance researchers need to conduct more ethical sma research the improvement of individual moral decisions can lead to an improvement not only on an individual level but might have positive implications on the society as a whole besides our practical contribution the study highlights the ethical concepts which are of relevance for is research and the need to spark discussions in our community to increase the positive impact of is research on both academia and society appendix a disclaimer the following manual serves as a complementing resource to the extended framework it resulted from the knowledge base the interviews and the focus group discussions each of the following aspects relates to an often highly complexethical debate please bear in mind that these questions and short descriptions are therefore not exhaustive feel free to contact us in case you find something missing thus protecting the researcher for example by carefully concealing their online identity is important for some areas of sma interviews • does the researcher need to be protected is the researcher confronted with disturbing material • does the researcher conduct research in a conflictual area which could put the researcher at risk due to the research results methodological reflection validity description this principle refers to the suitability of an analytical approach to answer a particular research question sma methods should be selected based on fit rather than habit for example social network analysis can be performed on almost all major sma datasets but results might not always be meaningful when using machine learning sma researchers often get a result that looks valid but do not have enough knowledge how the result was achieved burtonjones 2009 statement mean the extended framework would support me in planning and conducting more ethical sma research the extended framework is easy for me to understand 35 the extended framework is an addition provides added value to existing ethical guidelines table 8 assessment of the perceived usability and applicability of the framework after discussing the research design supported by the extended framework

en route to the unravelling of todays multiplicity of societal challenges making sense of social data has become a crucial endeavour in information systems is research in this context social media analytics sma has evolved to a promising field of datadriven approaches guiding researchers in the process of collecting analysing and visualising social media data however the handling of such sensitive data requires careful ethical considerations to protect data subjects online communities and researchers hitherto the field lacks consensus on how to safeguard ethical conduct throughout the research process to address this shortcoming this study proposes an extended version of a sma framework by incorporating ethical reflection phases as an addition to methodical steps following a design science approach existing ethics guidelines and expert interviews with sma researchers and ethicists serve as the basis for redesigning the framework it was eventually assessed through multiple rounds of evaluation in the form of focus group discussions and questionnaires with ethics board members and sma experts the extended framework encompassing a total of five iterative ethical reflection phases provides simplified ethical guidance for sma researchers and facilitates the ethical selfexamination of research projects involving social media data

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introduction in a recent editorial of this journal ikegami argues that middleincome countries which have achieved universal health coverage should introduce public longterm care insurance at an early stage before benefits have expanded as a result of ad hoc policy decisions to win popular support 1 his argument is based on a comparison of the introduction of public ltci in germany and japan in 1995 germany implemented a public ltci scheme with relatively limited services and an option for cash benefits according to ikegami germany was able to hold off major expansions of public ltci because at the time of introduction public coverage of longterm care services was largely absent by contrast in 2000 japan only introduced public ltci after access to ltc services was created by ad hoc expansions of public health insurance coverage and the social welfare schemes hence japan started with a more generous ltci scheme than germany which made it much more difficult to contain costs the ability to contain ltc costs may be especially relevant given that in many societies ltc expenditure is likely to grow due to a rapidly ageing population based on the experience of the netherlands however we question whether an early introduction of public ltc insurance is really key to restricting the expansion of publicly financed ltc services in 1968 the netherlands was by far the first country to implement a public ltc insurance scheme although initially only a limited number of ltc services were covered the scope of benefits was steadily expanded over time eventually this resulted in a much more generous scheme than the japanese with a level of public spending on ltc that is among the highest in the world 2 clearly the early introduction of public ltci did not prevent this hence the key question is why the germans were successful in preventing an expansion of public ltc insurance while the dutch were not and what lessons can be learned by middleincome countries contemplating about establishing public ltci our proposition is that the social norms about caring for elderly were of crucial importance for the moment of introduction of public ltci and its development we argue that the introduction of public ltci and the successive expansions reinforced the culturally based social norms that supported its early introduction before discussing our proposition in more detail we first provide a brief description of the evolution of the dutch public ltc insurance scheme in line with the description of the german and japanese schemes by ikegami 1 longterm care insurance in the netherlands in 1968 the netherlands introduced a universal mandatory social health insurance scheme by adoption of the exceptional medical expenses act there are several reasons why in the netherlands the choice was made for a universal public health insurance scheme for ltc 3 prior to 1968 the financing of ltc facilities was highly fragmented and increasingly insufficient to provide access to adequate care for lowerincome groups the strong economic growth during the 1960s substantially increased the general welfare of society since the financial risk of ltc was considered to be largely uninsurable on a private market there was broad political support to expand public financing to cover this risk moreover this was in line with the general social support for a rapidly expanding welfare state that would take care of the population from cradle to grave initially the awbz covered primarily nursing home care institutionalized care for the mentally handicapped and hospital admissions lasting more than a year in due course however coverage was expanded by including home healthcare eg for rehabilitation at home after hospital admission and care for elderly people with impairments ambulatory mental healthcare family care eg home help in case of frailty psychosocial problems or after childbirth and residential care for the elderly contributions and copayments were earmarked and incomerelated and collected in a national insurance fund from which providers were paid in 1995 cash benefits were introduced which eligible people can substitute for service benefits the role of culture and social norms the implementation of public ltci cannot be seen apart from social norms and cultural values for instance a negative relationship is found between family ties and expected coverage of ltci 4 therefore investigating social norms might add to the explanation why the netherlands were earlier than other countries to introduce ltc insurance according to hofstedes comparative model of national culture in which 6 different cultural dimensions are distinguished the netherlands is characterized by a highly individualistic and feminine society whereas the opposite holds for japan and germany being in between both countries 5 in individualist societies people are supposed to look after themselves and their direct family only by contrast in collectivist societies people belong to in groups that take care of them in exchange for loyalty feminine countries are inclusive and people value equality solidarity and quality in their working lives in feminine societies caring for others and solidarity are dominant values but the family structure is more flexible than the more traditional family structure in masculine countries hence although the demand for care for frail people is felt in society it could be less automatic that provision of this care is carried out within the family the combination of individualism and social solidarity in the netherlands may well explain the strong social support for extensive welfare state arrangements and the early adoption and subsequent expansion of a universal public ltc insurance scheme interestingly a similar culture of individualism and femininity is observed in sweden which is characterized by equally comprehensive publicly financed ltc arrangements a comparative study on the provision of elderly care in europe found that in the scandinavian countries and the netherlands the state is regarded as being responsible for providing care while there are only weak legal obligations for relatives to provide informal care 6 in the countries with familybased care systems like japan germany austria and most of mediterranean countries the responsibility for the care of an older person with needs is primarily borne by their relatives 67 compared to the netherlands in germany a much larger share of the respondents of the eurobarometer questionnaire of 2007 stated that parents should live with their children when an elderly father or mother who lives alone and can no longer manage to live without regular help because of her or his physical or mental health condition 8 by contrast in the netherlands more people responded that they should move to a nursing home nevertheless the preferences for institutional care in the netherlands are slowly changing as it became easier and more attractive to live longer independently in the community consequently the frailty of the population in nursing homes increased which may have contributed to a deterioration of the attractiveness of institutional care 9 once present the dutch public ltci scheme may have reinforced the culture of individualism and related social norms about caring for the elderly population the increasing access and availability of home and nursing home care made children less prepared taking responsibility for caring for their parents when getting old and in need of care hence letting a parent go to an elderly home or being assisted by professional home help and community nurses became the socially acceptable default option 8 the broad availability of formal ltc services may also have influenced the expectations of older adults about receiving those services when they get more dependent the same might be true for housing policies in the past in the netherlands since world war ii older adults have been nudged to elderly homes to combat the postwar housing shortage 8 furthermore over time the entire ltc provision in the netherlands became oriented towards older people becoming depended on publicly provided professional and institutional ltc services this has created a strong vested interest in maintaining and supporting the prevailing social norm by contrast the different familybased social norms in germany might explain why a strong expansion of public ltci did not happen there once the rather parsimonious public ltci scheme was introduced in 1995 the reason why the public ltci scheme in japan has been expanded despite the prevailing strong masculine social norms may be explained by a combination of strong social obligations for the family to provide elderly care and a rapidly ageing population 7 as pointed out by nakabayashi 7 the expansion of the public ltci scheme in japan may have produced a net social welfare gain as the benefits of alleviating families from the high burden of ltc provision may have outweighed the additional public expenditure on ltc policy implications the dutch experience show that an early adoption of public ltci is no guarantee to prevent or slowdown an expansion of benefits covered when this expansion is in line with the prevailing social norms and cultural values an early adoption of public ltci may even facilitate such an expansion because the introduction of publicly financed ltc may reinforce the prevailing social norms in view of an ageing population however the last decade dutch policymakers became increasingly worried about the financial sustainability of the generous public ltci scheme the call for cost containment became stronger especially after the severe economic recession of 2008 resulting in an intensifying societal debate on shifting the public responsibility for the provision of ltc partly to the citizens and their families and social network eventually after 10 to 20 years discussions and smaller policy measures to contain public ltc expenditure in 2015 this resulted in a major ltc reform by which the coverage of the public ltci scheme was restricted to institutionalized care and intensive home healthcare 1011 coverage of less intensive home care was transferred to the social health insurance scheme while municipalities became responsible for providing social ltc services especially for social ltc services peoples own responsibility has been reinforced since municipalities are only legally obliged to provide care if peoples family and social network cannot adequately support them although there is some weak evidence that the reform may have had some impact on the social norms concerning the provision of ltc these norms tend to be quite robust and difficult to change 12 moreover despite the major change in the way ltc is financed the extent of public provision of ltc has hardly been reduced conclusion ikegami posits that an early introduction of public ltci can prevent adhoc extensions the dutch experience shows however that an early introduction may not prevent but instead even facilitate such extensions prevailing social norms may well be the main driver of extensions of public coverage and are likely to be reinforced when the burden for informal caregivers is high furthermore we posit that the broad availability of publicly financed ltc is likely to have a perpetuating effect on the social norms supporting the extensions hence particularly in middle income countries politicians and policymakers should be aware of this possible selfreinforcing effect and have to weigh this against the social welfare gains from alleviating the burden for informal caregivers ethical issues not applicable competing interests authors declare that they have no competing interests

based on the experiences of japan and germany ikegami argues that middleincome countries should introduce public longterm care insurance ltci at an early stage before benefits have expanded as a result of ad hoc policy decisions to win popular support the experience of the netherlands however shows that an early introduction of public ltci may not prevent but instead even facilitate later extensions of public coverage we argue that social norms and cultural values about caring for the elderly might be the main driver of expansions of ltci coverage furthermore we posit that this expansion may reinforce the social norms supporting it hence politicians and policymakers should be aware of this possible selfreinforcing effect

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introduction about 295 000 women died during and following pregnancy and childbirth in 2017 the vast majority of these deaths occurred in lowresource settings subsaharan africa and southern asia accounted for approximately 86 of the estimated global maternal deaths in 2017 subsaharan africa alone accounted for roughly twothirds of maternal deaths 1 in ethiopia the maternal mortality ratio is 412 per 100000 live births 2 more than two in three women in ethiopia do not have access to health care 2 only 6 of the health facilities in ethiopia provides basic emergency and obstetric care and 55 of the women do not use the available service due to delay in decision making to go to the health facilities 3 lack of access to essential health care exposes the women to experience obstetric complications such as unfavorable pregnancy outcome maternal morbidity and mortality premature birth low birth weight and neonatal death 14 a strategy to reduce maternal morbidity and mortality birth preparedness and complication readiness plan was used as a prioritized intervention in order to reduce home delivery and decrease maternal morbidity and mortality 5 birthpreparedness and complicationreadiness is the process of planning for anticipating actions which will be needed in case of emergency encourages women and households to make arrangements to give normal birth by reducing delays in reaching care once a problem arises 56 it is crucial to decide on timely access to skilled maternal and neonatal services 7 finding from studies conducted in different african countries show that the majority of pregnant women were not having a birth plan 89 for example 35 of pregnant women were prepared for birth and related complications in mbarara district of uganda 10 and 27 in ungogo northern nigeria 9 despite different intervention to involve husband in participation in health care utilization by the government of ethiopia and other stakeholders most of the previous studies conducted in different parts of ethiopia showed that less than 20 of women practice bpcr plan involving husband 11 12 13 this is in particularly important as evidence from studies conducted in ethiopia shows that husbands were the independent decisionmaker on most family issues like the decision on selecting a health facility or trained health professional to manage delivery 111415 these conditions make husbands a critical role player for the improvement of maternal and child health involvement of husband during pregnancy and delivery may help to support pregnant women be ready for any emergency obstetric care if any complications happens 1617 study conducted among households targeting husbands with having at least one child of less than one year of age at mekele town showed that variables like husbands awareness of postnatal danger signs husbands knowledge in birth preparedness male involvement in antenatal care educational status economic status and place of residence were factors associated with husband involvement in bpcr plan 8 therefore the involvement of husband in bpcr during pregnancy labor the postpartum period and its complication helps an expectant mother to make timely decisions to avoid delays that bring about complications that could result in morbidity or mortality and for achieving sustainable development goals however little is known about the level of husband involvement in the study area which has different socioeconomic and cultural differences with the previous studies therefore this study aimed to assess the level of husband involvement in birth preparedness and complication readiness and associated factors materials and method study area and period this study was conducted in kucha district southern ethiopia which is located 440 km away from addis ababa and 172 km away from the capital town of gamo zone arba minch in the district there are 35 rural and one urban kebele in kucha district there were eight health centers 39 health posts and 15 private clinics this study was conducted from march 152018 to april 152018 study design a community based crosssectional study was conducted population all husbands whose wife gave birth in the last 12 months in the selected kebeles of the district and live for more than six months in the district were included in the study those who were critically ill during the data collection period and husbands who were not living with their wives were excluded from the study sample size determination the sample size for this study was determined using single population proportion formula 2 × p d 2 18 with the following assumptions 95 confidence level 80 power 5 marginal error and 508 prevalence of husband involvement in birth preparedness and complication readiness which is taken from study conduct in ambo town and 10 nonresponse rate 19 the final sample size was 421 sampling procedure simple random sampling technique was used to select the study subjects the district has 36 kebeles and 7 kebeles were selected by lottery method and then the calculated sample size was allocated proportionally to each kebele with consideration of the estimated number of husbands per each kebele the sampling frame containing a list of all married women who gave birth in the last 12months was obtained from a family folder of health posts in each health post there is a family folder that includes information about births number of children etc we obtained the list of women who gave birth in the last one year before data collection period accordingly we allocate sample for each kebele based on the available data of women who gave both in the last one year unique identifier number was given for each households finally from the list women who gave birth in the last 12 months were selected randomly using computer generated technique and their husbands interviewed in a private place around their home those husbands who were not available at first visit were revisited for the second times and those who were not available were revisited for the third times data collection tool the data collection tool was initially adapted from the survey tools used for maternal and neonatal health program which was developed by johns hopkins program for international education in gynecology and obstetrics 14 additional information was included from published relevant literatures 91415 20 21 22 23 the questionnaire consists of information about sociodemographic characteristics knowledge on danger signs during pregnancy male involvement in birth preparedness and complication readiness plan initially it was prepared in english the english version of the questionnaire was translated to the amharic language then to local language and backtranslated to english by language experts to check for its original meaning the questionnaire was pretested on 5 of the total sample in kucha town which was not included in the main data collection data collection procedures the data collected by trained data collectors using facetoface interview method of data collection a total of eleven diploma holders clinical nurses and four health officers were recruited for the data collection and supervision of data collection process respectively both data collectors supervisors were given a daylong intensive training on the data collection techniques research purposes and research ethics data quality management the questionnaire was pretested on 5 of sample size in kucha town which was not selected for the final study based on the pretest the logical sequence as well as skip patterns of the questions was modified moreover the time needed to complete an interview and the total number of days needed for data collection was estimated appropriate training for data collectors and supervisors was given which includes but not limited to the data collection process and the contents of the questionnaire the overall activity of data collection was supervised and coordinated by the supervisors after data collection the collected data were checked for its completeness by the principal investigator before and after data entry data were checked for any missing and inconsistencies data processing and analysis data were entered into epidata version 44 software and then exported to ibm spss version 240 statistical product and service solution for analysis then the data were cleaned to check for errors and missed values descriptive statistics using frequencies percentages mean and standard deviations were used to describe findings binary logistics regression was done primarily to check which variables had an association with the dependent variable multiple logistic regression analysis was conducted to identify the independent predictors of husband involvement in planning birth preparedness and complication readiness those variables that had a significant association in binary analysis were selected for multivariable analysis both crude and adjusted odds ratios with the respective 95 confidence intervals was reported and interpreted operational definitions men involved in birth preparedness and complication readiness practice men who are involved in at least in two birth preparedness plan 14 good knowledge about pregnancy danger signs husband who spontaneously mentioned at least two danger signs of pregnancy poor knowledge about pregnancy danger signs husband who did not spontaneously mention two danger signs of pregnancy 24 the key danger signs during pregnancy are severe vaginal bleeding swollen handsface and blurred vision 7 birthpreparedness and complicationreadiness is the process of planning for anticipating actions which will be needed in case of emergency encourages women and households to make arrangements to give normal birth by reducing delays in reaching care once a problem arises 56 result sociodemographic characteristics of study participants a total of 421 husbands were participated in this study with a 100 response rate the mean age of the respondents was 3411±55 years around half 489 of them had age range of 30 to 39 years old regarding their ethnicity the majority were gamo and 102 of them were government employees reproductive health and transportation three out of four study participants didnt arrange transportation for their wives thirty five percent of the participants travel more than five kilometer to reach the health facilities only 10 of study participants wife made decision by themselves to seek health care services knowledge of obstetrics danger sign during pregnancy almost all of the study participants were aware of that severe headache and blurring of vision was one of the danger sign during pregnancy three out of four study participants were aware that leakage of amniotic fluid as a sign of obstetrics danger signs nine out of ten had a good level of knowledge about the danger signs during pregnancy level of husband involvement in bpcr less than onethird of husbands 127 were involved in planning birth preparedness and complication readiness determinants of husband involvement in birth preparedness and complication readiness in the bivariate analysis significant association was observed between husband involvement in birth preparedness and complication readiness and the educational levels of husband the educational level of wife knowledge on danger sign of pregnancy frequency of anc visits if delivery was assisted if arrangement for transportation to the health facility were made and distance to reach health facility after adjusting for the effect of confounding variables using multivariable logistic regression educational level of husbands number of anc visits arrangement for transportation and distance to health facility were associated with husband involvement in birth preparedness and complication readiness husbands who had secondary and higher education were 31 times more likely aor 31 ci to be involved in birth preparedness and complication readiness plan than those who had primary and below educational level husbands whose wife attended four and 2 to be involved in birth preparedness complication readiness plan than those their counterparts families who lived far from a health care facility with a distance greater than 5km were 235 times more likely aor 235 ci 1403396 involved in birth preparedness and complication readiness plan than those who live in less than 5 km distance from health facilities husbands who have arranged for means of transportation previously were 29 times more likely aor 29 ci to be involved in planning birth preparedness and complication readiness than their counterparts discussion the main finding of this study is that only onethird of husbands were involved in planning a birth preparedness and complication readiness husband educational status number of antenatal care visits and living more than 5 km from health care facility were significantly associated with husband involvement in birth preparedness and complication readiness the level of husband involvement in birth preparedness and complication readiness was 302 this is lower than studies conducted in rural bangladesh endarta district ambo town and wolaita sodo town 15192025 this difference might be due to sociodemographic and socioeconomic differences such as low level of educational and economic status in the area of ethiopia where study took place which would contribute for lowlevel involvement in preparedness for birth however this finding is higher than the study done in southern ethiopia and two studies conducted in a rural hospital of rwanda 1421 this discrepant finding of our study and the one from gamo gofa zone could be related to the time of the study our study was done during the time the ethiopian governments gave special emphasis on health extension program to create awareness for rural communities on maternal healthrelated issues in which the women and their family had sufficient opportunities to hear about the important components of birth preparedness and complication readiness the free access for ambulance by the government may have also contributed to higher involvement in a birth plan as means of transportation is one components of birth preparedness and complication readiness plan this finding implies that despite the improvement of husband participation in the birth preparedness plan it needs further exploration of the reason for low participation in this study husbands educational level was one of the significant factors in promoting husband involvement in birth preparedness and complication readiness husbands who attend secondary and higher level of the school were involved in birth preparedness and complication readiness plan than those who attend primary school and below this finding is supported by the study from northern nigeria and ambo ethiopia 919 which indicate that the healthseeking behavior and involvement in health care decision making is improved with higher level of education of husbands this finding implies that education is a key for averting many problems including behavioral changes and in addition to increasing access to universal education it is important to increase the level of education in the society the frequency of anc visits was a significant predictor for husband involvement in birth preparedness and complication readiness plan husbands whose wife had four and more anc visits were more involved in birth preparedness and complication readiness plan than their counterparts this finding is similar to a study conducted in wolaita sodo town southern ethiopia 26 this finding indicates the need to increase the frequency of antenatal care this can be achieved if the ethiopian ministry of health implement the new antenatal care guideline for positive pregnancy by world health organization distance to the health care facility was one of the significant factors affecting husband involvement in bpcr plan husbands who live far from a health care facility with a distance greater than 5 km were more involved this finding is consistent with the studies conducted in wolaita sodo town 26 it is likely that husbands located less than 5km from health center were less concerned about birth complications as they live closer to the health facility this study showed that there is a significant association between prior arrangements of means of transportation with husband involvement on bpcr plan accordingly husbands who were arranging means of transportation before delivery were more likely to be involved in planning birth preparedness and complication readiness this might be due to the assumptions that being ready by planning and arranging one component of bpcr will prevent the delay in reaching health care facility this study might be exposed for recall bias due to the reason that information was collected retrospectively however to minimize the recall bias we reduce the duration of last birth to one year the other limitation as the study is cross sectional it is not possible to establish a cause effect relationship between the independent variables and outcome variable even though it is based on the reference of previous research the measurement of involvement in birth preparedness and complication readiness and the level of knowledge it was difficult to compare with some studies conclusion husbands involvement in bpcr is low in the study region of ethiopia husbands level of education the number of anc visits distance to the health facility and prearrangement of transportation were significant factors associated with the husbands involvement in bpcr therefore investing on antenatal care visits is crucial including the frequency of the care as it increases exposure with healthrelated messages including birth preparedness and complication readiness plan the more information women get from health care provider the more likely to they are to convince their husband to be involved in the health care decisions improving education level of men in the community is important to improve the involvement of them in the bpcr plan all relevant data are within the paper

birthpreparedness and complicationreadiness bpcr is the process of planning for normal birth and anticipating the actions needed in case of an emergency the involvement of husband during pregnancy helps a mother to make timely decisions to avoid delays identifying the level of husband involvement in birthpreparedness and complicationreadiness is very important as husband is the major decision maker in household and health service related issue however there is no sufficient data in the kucha district which describes the level of husband involvement in birthpreparedness and complicationreadiness therefore this study assessed the level of husband involvement in birth preparedness and complication readiness in kucha district gamo zone ethiopiacommunitybased crosssectional study was conducted on 421 husbands whose wife gave birth within the last 12 months at kucha district using simple random sampling technique data was collected using a pretested intervieweradministered questionnaire by trained data collectors binary and multivariable logistic regression with odds ratios along with the 95 confidence interval analysis were employed to find factors associated with the level of husband involvement a pvalue 005 with 95 confidence level used to decide statistical significancedata were collected from 421 study participants one hundred twentyseven 302 were involved in birth preparedness and complication readiness plan participants who had at least secondary school education aor 31 ci 184523 had at least four antenatal care visits aor 491 ci 236102 and live more than five km from the health care

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introduction globalisation digitalisation and technological development lead to increasing knowledge management and sharing in societies preparing university students to recognise the importance of knowledge sharing and transfer it later to their professional careers is the role of universities programmes and lecturers however a key role in knowledgesharing also plays in individuals according to aarons a natural assumption is that individuals have generated knowledge and that only one or more individuals can acquire it variables affecting the knowledgesharing attitude of individuals can differ and there are many factors theories and approaches considered by various authors in the literature significant ones include the phenomenon of altruism and social exchange theory regardless of whether it is a corporate or university setting the main aim of this paper is to theoretically and empirically contribute to the topic of knowledge sharing in the university and business context it investigates the levels of influences that stimulate knowledgesharing behaviour in the university environment for this purpose based on the literature review only some approaches were selected the social exchange theory and a factor of altruism as commonly used in the literature we use qualitative data from a sample of czech university students to analyse aspects of the social exchange theory for students we used all three dimensions of set data and findings are put in the context of the influence of the covid19 period the paper is based on the analysis of secondary data from a literature overview mainly related to knowledgesharing in educational contexts providing the background for the information needed to conduct the interviews knowledgesharing behaviour is studied from the point of view of altruism and willingness to share knowledge factors of altruism and social exchange theory are further analysed on qualitative data from a sample of czech university students based on the secondary data analysis qualitative data were obtained from semistructured focus groups on knowledgesharing behaviour among undergraduate students from the technical university of liberec according to isaacs based on pope and mays qualitative research is useful when the research focuses on complex issues such as human behaviour and felt needs therefore the goal of qualitative research is to help us understand social phenomena with the help of all participants views and experiences the university context participants were sampled using a systematic nonprobability sampling method this sampling strategy identifies specific groups of people who possess the studied characteristics respondents from the university were in the total number of 39 students randomly selected from chosen study programmes focus groups with semistructured interviews were conducted online from january to may 2021 the results of the interviews are further analysed in the following chapter knowledge management and knowledge sharing behaviour the theaetetus is arguably platos most significant work on epistemology where three definitions of knowledge are defined the first definition claims that knowledge is perception the second definition proposes that knowledge is true belief and the third one defines knowledge as true belief with an account nonaka classified knowledge as tacit and explicit working independently and leading the organisation to success explicit knowledge can be easily transferred and coded while tacit knowledge is rooted deep in the system in the organisation and is highly attached to individuals the distinction between tacit and explicit knowledge represents what is known as the epistemological dimension of organisational knowledge creation it promotes an ongoing dialogue between explicit and tacit knowledge which drives the development of new ideas and concepts knowledge management is profoundly indebted to many ideas derived from epistemology nonaka explicitly refers to philosophical insights in epistemology as the foundation for much of their pioneering work in knowledge management adhering to the traditional epistemology definition of knowledge as justified and belief philosophers believe that knowledge can be acquired through experience according to biggam if an experiential view of knowledge was adopted in a university context students could only claim to have acquired knowledge if the courses which they studied contained practical elements on the other hand employers and universities may partially support the empiricist argument by placing a high value on student work experience programs such experience is frequently regarded as valuable improving a students education and possibly reflecting a preference for experiential knowledge over theoretical knowledge according to arief et al knowledge sharing is a process where individuals disseminate their knowledge to others according to arsawan et al based on bari et al knowledge sharing is referred to as employees willingness to share information with other individuals in the organisation knowledge is highly individualistic and rooted in specific social cognitive and behavioural contexts therefore dyadic cohesion becomes a critical element in the knowledgesharing process the authors discussed the epistemological approach to knowledge sharing in the book philosophical foundations of knowledge management other authors propose a simple knowledgebased theory of the firm with the idea of a legal entity that holds the undivided residuals and outputs of teamwork thus individuals can learn and share outcomes with others within the firm with the firm manifesting as a body of shared and held knowledge this could mean an epistemological challenge given that knowledge is an archetypal nonrivalrous good extensible and shared with others without losing oneself yet many authors consider knowledge sharing a knowledge management challenge that needs to be addressed some authors argue that employee knowledge is not so much an extractable asset as embedded knowing the epistemological critique occurs when an organisations knowledge is defined as shared collective or an attribute of a community of practice according to spender and scherer epistemology of practice unlike the familiar realist or phenomenological epistemologies cannot spin around defining knowledge in terms of mind instead it must be focused on living or indwelling on our competence as human agents to negotiate our experiences several theories have been applied to study knowledgesharing behaviour so far in the literature the authors often use the theory of reasoned action or the social exchange theory tra focuses on the construction of a system of the observation of two groups of variables which are attitudes defined as a positive or negative feeling concerning the achievement of objective and subjective norms representing the individuals perception concerning the ability to reach those goals with the product we selected the set approach for this paper introduced in more detail in the following chapters knowledgesharing among university students is considered an important and exciting area of study in the academic world higher education institutions create and deploy knowledge amid their practices and activities this knowledge management and innovation in higher education are as crucial as in the corporate sector in an hei knowledge management can be a way to make learning actionable for more people eg for the association overall in research or innovation knowledge exists at multiple levels within an organisation individual group and organisational knowledge sharing is essential because it links the individual and the organisation by transferring knowledge that resides with individuals to the organisational level where it is transformed into the economic and competitive value for the organisation empirical evidence on the relationship between reciprocity and knowledgesharing shows that receiving knowledge from others stimulates a reciprocal flow of knowledge towards the sender in organisations both horizontally and vertically the following chapters describe other factors which could influence the knowledgesharing of the individual altruism as an aspect of knowledgesharing recognising that altruistic individuals are prone to share knowledge willingly managers can respond by assigning specific roles to altruistic individuals in teams and giving them tasks in which they would collaborate and engage in socialisation with others such choices could foster group knowledgesharing altruism is a stimulating factor in sharing behaviour and positively influences the quantity and quality of shared knowledge research on altruism began to develop in the 1960s a significant theme from the beginning was whether personality traits could contribute to explaining helping behaviour or whether the situational factors facing potential helpers were of primary importance according to kankanhalli et al the benefit of enjoyment in helping others is derived from the concept of altruism previous research shows that knowledge contributors gain a satisfactory fraction by demonstrating altruistic behaviour people who behave altruistically share information because they want to give something to others to show concern and care or to reduce the distress of the other person altruism has been described variously as providing unconditional kindness with no expectation of return helping and achieving a sense of satisfaction from doing so and helping others without regard to whether they receive anything in return altruism has a direct significant and substantial effect on online knowledgesharing behaviour moreover altruism helps reduce conflict and promote collaborative processes according to the wu et al study on the relationship between interpersonal trust and knowledge sharing along with the impact of individual altruism employees altruistic traits make it easier for them to share knowledge in the workplace colleague trust has a more significant effect on explaining the act of knowledge sharing for lowaltruism employees than for highaltruism employees for highaltruistic employees colleague trust is not central to knowledge sharing therefore individual altruism has both direct and moderating effects on knowledge sharing chang and chuang found out in their research that intrinsic benefits seem to have a more significant influence on online knowledge sharing than extrinsic rewards the results of choi et al study show that altruism is another significant motive for the intention to share knowledge on social media it indicates that people like to share their knowledge on social media because they expect their knowledge to be helpful to others according to brouwer and jansen altruism and belonging or identification with the community positively contribute to social exchanges and knowledge sharing for personal benefits pee discusses altruism as an aspect showing the communitys need for knowledge sharing in the example in wikipedia table 1 summarises the literature review on the factors influencing knowledgesharing behaviour table 1 secondary data results on the factors influencing knowledgesharing behaviour author and year of study key finding wu et al according to the authors study on the relationship between interpersonal trust and knowledge sharing along with the impact of individual altruism employees altruistic traits make it easier for them to share knowledge in the workplace and colleague trust has a greater effect on explaining the act of knowledge sharing for lowaltruism employees than for highaltruism employees for highaltruistic employees colleague trust is not of central importance in knowledge sharing therefore individual altruism has both direct and moderating effects on knowledge sharing social exchange theory and willingness to share knowledge unlike the altruistic view which posits that people share knowledge to help others without expecting any reward social exchange theory takes a more egocentric view it predicts that people only invest in others when they can expect a valuable payoff in the future or seek to return value for resources acquired in the past social exchange theory investigates individual behaviour as a rational social phenomenon based on a subjective costbenefit approach social exchange theory assumes that individuals participate in social interactions based on the belief that this will lead to inevitable social rewards such as recognition status and respect social exchange theory assumes that people behave in ways that maximise their benefits and minimise their costs according to social exchange theory the willingness to transfer knowledge is high when mutual benefits are anticipated the author and year of study key finding chang and chuang results of the study invented those intrinsic benefits that seem to have a greater influence on online knowledge sharing than extrinsic rewards ma and chan altruism has a direct significant and strong effect on online knowledge sharing behaviour moreover altruism helps reduce conflict and promote collaborative processes sedighi et al their study explored participants perceived benefits and costs influencing participation in knowledge networks the results indicated that altruism reciprocity and reputation are perceived benefits that influence the quality of employee participation matić et al based on the data from public and private sectors factors such as organisational climate empowering leadership innovativeness and affiliation sense of selfworth and altruism significantly influence individuals knowledgesharing attitude brouwer and jansen 2019 according to authors altruism and belonging or identification with the community positively contribute to social exchanges and therefore to knowledge sharing for personal benefits choi et al the results of their study show that altruism is another significant motive for the intention to share knowledge on social media it indicates that people like to share their knowledge on social media because they expect their knowledge to be useful to others fischer fischer developed and validated a scale to measure knowledgesharing motives of employees at work the scale was tested on data from the core public and health sectors the study found that appreciation growth and altruism are three dimensions of knowledgesharing motives jameel et al the authors examined the impact of selected factors on the online knowledge sharing among employees of four private banks their results indicated that altruism reputation selfefficacy reciprocity and enjoyment have a positive and significant effect mutual exchange takes place in trusting relationships with coworkers built over time while this reciprocity appears beneficial to the employee it also benefits the organisation based on a metaanalysis liang et al state that social exchange is the most popular theory in explaining knowledgesharing behaviour these authors presented a model where individual cognitions interpersonal interaction and organisational efforts are identified as three aspects influencing individual knowledgesharing behaviour these authors discuss in connection with social exchange theory the contribution of personal factors interpersonal factors and organisational factors see the figure organisational commitment is an individual factor describing the level and type of psychological attachment that an employee or student has with an organisation these authors also point out that an individuals commitment can encourage him or her to share knowledge due to the sense of responsibility this commitment is a strong determinant of individual knowledge sharing individuals often share knowledge not only due to their altruistic attitude but because of perceived benefits they expect to benefit from active participation in a social group and they can expect that their contribution to knowledge sharing will help them to improve their reputation or social status within a specific group employees or students will contribute to sharing knowledge within the organisation relative to their level of organisational commitment on the organisational level from the point of view of social exchange theory and knowledge sharing suppose that organisations care about employees wellbeing and value their contribution supportive relationships between an employee and an employer are built on the trade of effort and loyalty for benefits such as pay support and recognition organisations can motivate employees to share knowledge through tangible and intangible rewards covid19 pandemic and its effect on knowledgesharing the covid19 pandemic posed a tremendous challenge to universities and organisations worldwide especially those which were not prepared to switch their way of working significantly from day to day organisations that used knowledge management processes before the pandemic leveraged existing practices but were also compelled to critically relook at the efficacy and effectiveness of those already used km practices and processes according to tomé et al the covid19 crisis happened as a crisis about knowledge namely we assume that a massive knowledge failure was at its core and made the crisis grow namely on the one hand the absence of a vaccine and the cure for covid19 the massive problem of social knowledge linked with organisational behaviour which was solved with social distancing set of measures like working from home whenever it was possible according to jennex and raman knowledgesharing culture plays a crucial role in knowledge management the tools and processes do not deliver the desired results if such a culture does not exist teaching underwent a significant change because it was no longer possible to teach facetoface as a result teaching has moved online which has caused significant problems in terms of digitisation and internal knowledge management processes knowledgesharing activities are essential as knowledge transfer between students helps foster a knowledgesharing culture at the university the pandemic has shown that an organisations effective knowledge management systems and processes are very important for employees platforms for sharing creating and exchanging knowledge were already available to all employees before the pandemic however the awareness and usage of km systems and practices improved during the pandemic this strong and positive outcome highlights that knowledge management is no longer a trend as the pandemic necessitated practices such as collaborative capture use transfer and conversion knowledge sharing among students key findings based on the qualitative data analysis the results presented in this part of the paper show key similarities between students and employees knowledgesharing behaviour the structure of respondents from the university students is presented in table 2 below the students were interviewed between january and may 2021 online via google meet each semistructured interview took 25 h and in all discussions students from the faculty of economics technical university of liberec participated we interviewed 39 undergraduates from masters and bachelors programmes during the interviews students were enrolled in their studies entirely online and had no chance to meet in person during classes or at dormitories in groups 25 students experienced present teaching and courses at the university before the covid19 pandemic they confirmed that this helped them with knowledge sharing during the online period of taking classes and cooperation the only group of students who shared the information in person was group 1 where the students were erasmus students from different european countries and stayed in dormitories these factors could also influence the attitude of students toward knowledge sharing table 3 shows the main findings regarding the aspect of altruism among the interviewed groups social exchange theory overall students see as an essential environment for sharing in the campus classes and dormitories they share knowledge mainly in smaller groups and intensified online sharing a lot during the online period none of the groups declared a reason for sharing the financial reward however they stated the organisational commitment on the individual and group level and it means that it encourages them to share knowledge due to the sense of responsibility in all groups some students expressed an altruistic approach to sharing discussion and research limitations based on the literature review and for this paper the authors discuss the theoretical philosophical approach to knowledge management and knowledge sharing further we selected the social exchange theory and altruism as factors to be analysed both in the literature review and primary qualitative data our paper brings findings of this theory from a group of university students of this theory on a sample of qualitative data data were collected during the covid19 period in the czech republic based on five interviews with various groups of university students the authors found out that for students at all three levels factors in set defined by lin et al are usable for the collected data the findings show an overall willingness to share knowledge with individuals which most respondents pointed out students stated that it is even more intensive and in most cases happens mainly online the context with altruistic behaviour was quite significant the influence of factors of set on the group level was also seen in most of the interviewed groups students were aware of their reputation or social status within a specific group where they cooperated with and believed that it might increase if they participated in knowledge sharing at this level in the context of the organisation none of the aspects of set as loyalty for benefits such as pay support and recognition were identified in none of the groups were students rewarded tangibly or intangibly by the organisation limitations of these findings are in the sample size as the results come only from 39 czech university students in five focus groups therefore it is not possible to generalise these findings the focus groups of students were only from one faculty at the czech university also only some factors and theories are used in this paper in the literature review and qualitative data analysis however the results cover a topic not profoundly described in the literature and also bring very topical findings related to the covid19 pandemic conclusions and future work there are many theories factors and approaches to analyse the environment of knowledge sharing of employees in organisations also philosophical and epistemological issues are discussed in the literature not so many authors pay attention to the context of university students especially if we search for authors and data in the european context as lin et al point out many papers have reported findings about factors that affect knowledgesharing intention and behaviour based on several theories such as the theory of reasoned action or the social exchange theory the social exchange has been the most popular in explaining knowledge sharing the authors of this paper used set to analyse the knowledgesharing aspects of the qualitative data of czech university students they thus bring a view of a very current topic in the context of the impact of the covid19 pandemic on the approach of individuals to sharing knowledge in the environment of universities moreover the topicality of the issue and the possibility of expanding quantitative data collection and investigating other factors and approaches give the authors room for further research including international comparisons t e r e z a m i c h a lo vá k at e ř i n a ma r š í ko vá epistemologinis požiūris į dalijimosi žiniomis problemas universitetuose covid19 pandemijos metu altruizmas ir socialinių mainų teorijos kontekstas santrauka literatūros specialistai ir mokslininkai plačiai diskutuoja apie dalijimosi žiniomis sampratą šiuo straipsniu siekiama pateikti teorinius žinių dalijimosi pagrindus atsižvelgiant į pasirinktus veiksnius tokius kaip altruizmas ir socialinių mainų teorija taip pat aptariamas epistemologinis požiūris į žinių valdymą ir dalijimąsi žiniomis pagrindinis šio darbo tikslas teoriškai ir empiriškai prisidėti prie dalijimosi žiniomis universitete straipsnyje taip pat aptariamas altruizmas ir studentų dalijimasis žiniomis studentai vertinami kaip individai kurie gali tikėtis pripažinimo už dalijimąsi savo tyliomis ir aiškiai išreikštomis žiniomis duomenys patvirtina kad tarp studentų dažnai vyrauja altruistinis požiūris jei jie tikisi pripažinimo tai daugiausia grupės lygmeniu studentų respondentų grupės taip pat pateikė išskirtinį požiūrį į covid19 pandemijos įtaką dalijantis žiniomis raktažodžiai dalijimasis žiniomis altruizmas socialinių mainų teorija universitetų studentai verslas

professionals and researchers in the literature widely discuss the concept of knowledge sharing this article aims to provide a theoretical framework for knowledge sharing from the perspective of selected factors such as altruism and social exchange theory set and also discusses an epistemological approach to knowledge management and knowledge sharing the main aim of this paper is to theoretically and empirically contribute to knowledge sharing in the university context the paper also discusses the altruism and knowledge sharing of students as individuals who may expect some recognition for sharing their tacit and explicit knowledge data confirm that there is often an altruistic approach among students if they expect recognition it is mainly on a group level groups of student respondents also gave a unique perspective on the influence of the covid19 pandemic on the attitude toward sharing knowledge

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introduction the novel coronavirus disease has become a public health emergency worldwide after being declared as a pandemic by the world health organization in march 2020 the united states is among the mostaffected countries and with near six million cases and 190000 deaths in the first six months 1 deep south states such as mississippi and louisiana with already existing health and social inequities were expected to bear a disproportionate burden from the pandemic early studies reported that african americans had greater hospitalization rates from covid19 in comparison to other races but also pointed out the underlying factors such as chronic disease burden residence in lowincome areas or occupational exposures that could result in a greater risk of covid19 infection 23 a recent study reported that higher perceived risk for covid19 was associated with greater income and younger age 4 as of september 13 2020 mississippi and louisiana reported a cumulative of 87805 and 154955 cases respectively 5 louisiana became an epicenter among southern states as early as april and was the third highest in per capita reported cases in the us 6 mississippi had a more steady increase in the number of cases but had the second highest covid19 hospitalization rate in the nation by early june 7 the emergence of covid19 cases and scientific and medical uncertainty of disease surveillance urged public health officials and statelocal governments to identify and implement interventions to slow the spread of disease 8 nonpharmaceutical public health interventions such as social distancing and isolation have been shown to be simple and costeffective ways to control respiratory infections 9 the center for disease control and prevention has also identified npis as one of the best ways to control pandemic illnesses when vaccines are not yet available 10 by early april both mississippi and louisiana issued stayathome orders and stated guidelines that included mask mandates restrictions for nonessential businesses and social distancing to slow the spread of covid19 stayathome orders in both states directed residents to stay at or shelter at home and limit movements outside of their homes beyond essential needs there is still much too be learned about medical experiences related to the pandemic as well as attitudes and other factors related to stayathome order adherence additionally it is critically to understand the factors related to stateathome order adherence to better inform intervention and policy design the purpose of this study was to describe covid19 related symptoms and medical care experienced in the first six months of the pandemic as well as stayathome order adherence and attitudes related to covid19 risk and social distancing among a diverse sample of adults in the deep south specifically in the states of louisiana and mississippi additionally we determined predictors of stayathome order adherence methods study setting and participants adults 18 years of age and older who resided in mississippi or louisiana were recruited for the study via social media posts the posts were shared to various social media pages and promoted by mississippi inbre outreach scholars and community partners the data collection period occurred for three weeks in june 2020 the survey was developed to support the research of the mios summer research program the survey was delivered online lasted approximately 15 to 20 min and began with an overview of the study and informed consent information participants were informed that the purpose of the survey was to conduct a health assessment in mississippi and louisiana that include questions related to demographics standard health information health views and attitudes and nutrition physical activity and covid19 behaviors participants were also informed that the information gathered may be utilized for research purposes or by agencies and organizations to develop programs or provide resources to address community needs initial questions were presented to determine study eligibility based on age and state of residence individuals who did not live in louisiana or mississippi or were less than 18 years of age were excluded from participation in the study after completing the survey participants were offered the opportunity to accept a 5 walmart electronic gift card all study procedures were reviewed and approved by the university of southern mississippi institutional review board measures the survey included items related to nutrition physical activity covid19 and preventable chronic disease standard demographics and medical history information included items such as raceethnicity gender educational levels individual and household income household size religion and religiosityspirituality chronic disease information for self and familyhousehold members the study adoptedadapted items from centers for disease control and prevention covid19 community survey 11 to collect detailed information regarding covid19 related symptoms medical care sought for covid19 related symptoms covid19 related attitudes and social distancingstayathome adherence behaviors to assess covid19 related attitudes participants selected their agreement on a 7point likert scale with the following six statements 1 i have a greater risk of covid19 2 i live in a neighborhood where it is difficult to socially distance myself from others 3 it is easy for me to socially distance from family members in my home 4 it is more important to be with my family than to socially distance from them and 5 it will help decrease the spread of covid19 fi i stay away from other people including my family social distancingstayathome order adherence behaviors were yesno responses for having done any of the following behaviors during the stayathome order time period 1 gone out to a restaurant bar club or other place where people gather 2 visit with friends relatives or neighbors aged 60 years or older 3 gone to the grocery store or pharmacy 4 gone to a friend neighbor or relatives house 5 had more than 10 friends neighbors or relatives over for a gathering or meal 6 gone to a family gathering with more than 10 people 7 gone to a gathering of friends with more than 10 people and 8 gone to a faithbased gathering the question stem was during the month of april 2020 have you … and participants were asked to select all that apply other items collected and not included in this study were fatalistic attitudes related to preventable chronic disease dietary and physical activity behaviors peer social support for diet and physical activity and community health values related to preventable chronic diseases statistical analysis descriptive and frequency data were computed for all variables and all analyses were conducted using ibm spss statistics 270 software to determine whether covid19 related attitudes predicted social distancing stayathome adherence behaviors net of the effects of demographic and psychosocial variables we proceeded through a series of steps to determine which variables to include in the final model first simple correlations among demographic variables and psychosocial variables were computed eight hierarchical binary logistic regression models were used to test the contributions of demographic psychosocial and covid19 related attitude variables on each of the social distancestayathome order adherence variables results demographics impact of covid19 on employment and medical history 411 participants attempted survey completion of the 411 participants 99 of participants completed all of the demographic information 97 reported on whether they had been diagnosed with a chronic disease 97 reported on whether or not they experienced covid19 symptoms 91 reported on social support and 90 reported on covid19 related attitudes and behaviors the decrease in responses followed the order of questions in the survey with questions asked early in the survey having higher response rates compared to those answered later in the survey those who completed the survey were on average older compared to those who did not complete the survey 569 p 02 more educated and more likely to be married compared to noncompleters but not different with regard to race employment status or income demographics for the 368 participants who completed the survey are located in table 1 the final surveyed sample of deep south residents was relatively young with 781 of respondents 45 years or younger and an age range of 18 to 79 years most respondents were female married or single had at least some college reported an individual annual income of 59999 or less and about half reported employment in a fulltime position about half reported zero children followed by one to two children living in the home and one to three adults living in the household most respondents were baptist followed by nondenominational and catholic most participants reported that they were fairly or very religious table 1 provides detailed information for demographic data 297 of participants reported that the covid19 pandemic caused them to work remotely or from home more than usual 146 183 and 177 either worked more hours than usual worked fewer hours than usual or were not able to work respectively only 51 had difficulty arranging childcare and 09 had incurred increased childcare costs 143 experienced reduced incomepay and 83 were not paid at all covid19 related symptoms and medical care 214 of the 368 participants reported not experiencing any of the five covid19 related symptoms between january and july 2020 of those who reported at least one symptom the most reported symptom was a runnystuffy nose followed by sore throat and cough nearly half of those who experienced at least one symptom went to a healthcare professional for the covid19 related symptom less than a quarter of those individuals who sought medical care for a covid19 related symptom were tested for covid19 and 486 were tested for influenza the most common healthcare setting visited was a doctors office followed by the urgent care center most individuals who did not seek medical care for covid19 related symptoms reported they did not do so because the symptoms were not considered severe enough to seek medical care those who selected the other response indicated the following reasons for not seeking medical care had sinusallergy issues avoided missing workschool or selfmedicated table 2 provides complete information for quantitative data covid19 related behaviors and attitudes during the month of april 2020 which is the time period when both states of mississippi and louisiana were under a stayathome order the majority of respondents visited a grocery storepharmacy followed by visiting a friend neighbor or relatives house and visited with friends relatives or neighbors aged 60 years or older only 75 of respondents did not visit any of the places or do any of the activities listed other social distancingstayathome adherence behaviors are described in table 3 549 of participants somewhat disagreedtostrongly disagreed that they have a greater risk of covid19 complications 813 of participants somewhat disagreedtostrongly disagreed that they live in a neighborhood where it is difficult to socially distance from others 410 of respondents somewhat agreedtostrongly agreed that it is more important to be with family than to social distance 625 of participants somewhat agreedtostrongly agreed that staying away from other people including family would help decrease the spread of covid19 a complete distribution of data is reported in table 4 correlation and regression analyses power analysis indicated that a sample size of 300 was needed to detect between a small and medium effect size to test for the relation between covid19 behaviors and the five covid19 attitudes over and above the explanatory power of demographic variables 5 and psychosocial variables 3 simple correlations among demographic and psychosocial variables revealed at most moderate correlations between predictor variables moderate correlations were also noted among attitudes related to covid19 risk and social distancing and social behaviors related to stayathome order adherence findings indicated that the older the participants and greater agreement that it will help decrease the spread of covid19 if i stay away from other people including my family the less likely participants were to report going to a restaurant bar club or other place where people gather the younger and more educated the participants and the greater the agreement with it is more important to be with my family than to socially distance from them the more likely to report having gone to a friend neighbor or relatives home the greater the importance to be with family than to socially distance from them the more likely they were to report attending family gatherings of 10 or more people the greater the agreement that they lived in a neighborhood where it is difficult to social distance the more likely they were to have gone to a gather of friends with more than 10 people the more religious the participants the more likely they were to report having gone to a gathering with friends with more than 10 people or attended a faithbased gathering table 7 contains complete regression analyses results discussion this study identified covid19 related symptoms and medical care during the first six months of the pandemic and described attitudes demographic and psychosocial factors that were related to social distancingstayathome adherence behaviors during statewide stayathome mandates our findings indicated that near half of participants who experienced covid19 related symptoms between january and july 2020 sought medical care at predominantly doctors offices and urgent care centers most of the other half did not seek medical care for symptoms because they did not feel symptoms were severe enough for medical care approximately twothirds of participants reported that they disagreed that they were at greater risk of covid19 complications and agreed that staying away from other people would decrease the spread of covid19 an overwhelming majority reported that they lived in a neighborhood where it was not difficult to social distance from others several factors including demographics psychosocial and covid19 attitudes were related to a greaterlessor likelihood of stayathome order adherence npis such as stayathome orders have been shown to reduce the spread of disease including reduced rates of covid19 cases 12 a current longitudinal study found that individuals living in highly populated areas made less frequent essential trips to places like the grocery store or pharmacy and were more likely to adhere to social distancing guidelines 13 louisiana and mississippi are largely rural states and most participants did visit a grocery storepharmacy during the stayathome order period it should be noted that our sample was composed of a greater proportion of women who could be caretakers of their home and responsible for the food and other household necessities another study in bangladesh women was similar where 891 of 2424 respondents reported leaving the house for shopping necessities during the over twomonth stayathome order 14 additionally near half of our sample reported changes to employment that would worsen socioeconomic conditions while stayathome orders may reduce or slow disease incidence economical and psychological impacts have also been reported at individual and community levels among other populations 1415 this is important to consider especially in the deep south where underserved populations already experience disparities in many areas which could be exacerbated by stayathome orders most participants reported as fairlyvery religiousspiritual and some type of religious affiliation this region of the country is among the highest for church attendance compared to other states and regions of the us 16 other research has shown that attending places of worship within two weeks prior to testing positive for covid19 had higher likelihood of testing positive for covid19 17 our research shows that religiosityspirituality did increase the likelihood of having attended a faithbased gathering during the stayathome order this could be a unique contributor to the spread of covid19 in this region attitudes about staying away from other people to prevent covid19 and the importance of family over social distancing along with age was associated with the likelihood of going where other people gather found that nonadherence to selfisolation behaviors was associated with younger age groups 19 this could be attributed to public health messages that olderelderly adults were at a greater risk of covid19 complications compared to younger populations those who placed greater value on being with family than social distancing were more likely to go to a family gathering of more than 10 people and to a friend neighbor or relatives house prior research has shown that individuals who tested positive for covid19 reported significantly more close contacts with a person with known covid19 within the two weeks prior to being tested compared to those who tested negative for covid19 20 of those that had a close contact with an individual who tested positive for covid19 family was the most commonly reported relationship of the close contact with covid19 accounting for about 50 of the responses followed by work colleague and friend 20 the reported results highlight unique cultural and contextual factors that may influence stayathome order adherence and possibly other npis during a similar time period the first two weeks of may 2020 774 830 and 846 of a us los angeles and new york city sample respectively reported no contact with anyone outside of their home as a covid19 mitigation strategy 21 similarly 751 to 776 of those samples reported always avoiding groups of 10 or more people 21 this is starkly different from our results where only 75 of our sample did not visit any of the places or do any of the listed activities where visiting or gathering with other people was involved as mentioned earlier there may be geographic attributions to stayathome order adherence in addition to socioeconomic and cultural considerations however the corsair study reported that going to the grocery storepharmacy was one of the reasons for not selfisolating when presented with possible covid19 symptoms 19 this study also reported that feeling better was another reason for not selfisolating which was similar to our results study strengths include a respectable sample size while the sample size was adequate for our purposes and was diverse in terms of raceethnicity it does not necessarily represent the entire population of louisiana and mississippi compared to 2019 us census data for the states of louisiana and mississippi 2223 our sample had approximately 24 more women 11 less individuals with only a high school education 17 more american indianalaskan natives and 16 less whites the electronic survey was an ideal data collection method amidst a pandemic and our approach leveraged widely used social platforms however bias may be introduced due to social media use and internet access required of our approach other limitations include biases associated with selfreport measures we also do not know the frequency of the social behaviors exhibited during the stayathome order which could influence results conclusions as the us continues to manage the pandemic and identifies strategies to mitigate the transmission of covid19 cultural and contextual factors need to be considered to identify state level strategies for most effective npi implementation as future stayathomelockdown recommendations are considered by policy makers understanding how social values life stage socioeconomic and geographic factors influence stayathome order adherence would lead to more effective policy design to improve population adherence authors contributions jl were informed the design of the study and provided study oversight as well as was a major contributor in forming the manuscript tg implemented the statistical analyses and was a major contributor in forming the manuscript sa facilitated data collection and development of manuscript components la dw jg and me provided external review of the study and were major contributor in informing the manuscript all authors read and approved the final manuscript competing interests authors report no competing interests

objective to describe covid19 related symptoms and medical care experienced in the first six months of the pandemic as well as stayathome order adherence and attitudes related to covid19 risk and social distancing among a diverse sample of adults in the deep south methods survey data were collected from 411 louisiana and mississippi residents for three weeks in june 2020 through social media results over half 525 of participants who experienced covid19 related symptoms with 415 experiencing at least one symptom did not feel the severity of symptoms warranted seeking medical care 916 of the deep south adults visited certain places or did activities where visiting or gathering with other people was involved during stayathome mandates religiosityspirituality age education number of children in the home attitudes related to covid19 risk of complications and social distancing were related to the greaterlesser likelihood of stayathome order adherence conclusions various cultural and contextual factors were related to stayathome order adherence understanding how social values life stage socioeconomic and geographic factors influence stayathome order adherence would lead to more effective policy design to improve population adherence

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introduction intimate partner violence refers to behavior that occurs in a current or previous intimate relationship which causes physical psychological or sexual harm it includes acts of physical aggression sexual coercion and various forms of psychological or emotional abuse the latter may include humiliating threatening and coercive behaviors designed to control the victim and limit her autonomy exposure to ipv is a cause of injuries and physical harm and it contributes to mental health problems including depression posttraumatic stress disorder and suicidality spencer et al aspects but also of social structure which includes clear role definitions norms and stereotypes the study focuses on the differences in the tendency to ask for help in cases of ipv between jewish and arab women living in israel with the understanding that helpseeking depends among others on cultural and social codes literature review sectoral di erences in ipv against women in israel israeli society consists of many sectors and population groups but the phenomenon of ipv is present in all of them studies that examined the differences between the diverse groups have found that arab women born in israel have the highest rate of ipv victimization 21 in the israeli population in a survey conducted among women of childbearing age in israel considerable differences were found in the prevalence of ipv among arab women born in israel jewish women born in israel and immigrants to israel all types of ipv were more frequent among arab women and recurrence was higher than the other two groups arabs are a minority in israel the arab population of israel which includes muslims bedouins christians and druze constitutes about 21 of the total population of the country the arab society is different in many respects from jewish israeli society although the differences are not completely dichotomous and unequivocal in general the arab society is more traditional collectivist and patriarchal and the jewish society is more individualistic and liberal despite the modernization processes that arab society is undergoing and the increase in the rate of arab women working outside the home and acquiring higher education arab society remains patriarchal which places women in a low position in the family hierarchy the womans roles as a wife and mother and expectations of her remain the same even if she carries the additional burden of working outside the home according to sweet romantic relationships are the arena where traditional gender ideologies are upheld most strongly this is also reflected in the phenomenon of violence and murder for the sake of family honor in arab society in israel tendency to seek help ipv has many implications both physical and mentalemotional women who are at risk from their partner are likely to experience increased levels of stress tension and anxiety and are required to develop strategies for coping with their physical mental and emotional state at times they are required to defend their lives coping is a regulatory process used to reduce the negative emotional effects of stressful events coping strategies refer to methods adopted and practiced by people as means of dealing with various stressors multiple coping strategies are influenced by intrapersonal and environmental factors one of them is seeking external support and help the present study examined the probability of seeking external support by jewish and arab women as well as the possible sources of support several articles have proposed a theoretical framework explaining the inclination to seek help in cases of ipv lelaurain et al conducted a systematic literature review and identified three phases in ipv helpseeking problem identification decision to seek assistance and determining whom to engage for urgent aid however these processes do not occur in isolation but within a socialcultural framework liang et al assert that the definition of ipv and a persons recognition of being a victim of ipv are influenced by the societal and cultural norms that shape the interaction between gender class and culture as suggested by waller et al in the theory of helpseeking behavior this theory takes into account survivors sociocultural context intersectionality and beliefs examining how these factors influence the nature and extent of their helpseeking behavior it postulates that womens beliefs and experiences with available support as well as their individual agency impact how and when they seek crisis aid the theory of helpseeking behavior includes three key constructs social context which explains how survivors sociocultural context influences their efforts to seek help beliefs particularly their lived experiences and reflections on available services and support and agency encompassing the strength or power they employ to secure assistance hence the cultural and social environment is closely linked to the decision to seek help the barriers that hinder it and the factors survivors choose to turn to the barriers encountered during helpseeking depend on survivors sociocultural context and whether they seek aid from formal providers these barriers range from shame and stigma to denial of the abuse occurring and aligning with the perpetrator according to this theoretical concept several studies have shown that the decision to seek help and the decision to whom to turn are affected by socialcultural perceptions studies conducted in collectivist and patriarchal societies found that women are expected to retain their honor by remaining hidden and maintaining a low profile restricting their autonomy and abiding by various constraints to uphold their reputation and that of their family hulley et al conducted a qualitative metasynthesis of 47 papers analyzing samples of women from diverse cultures including african hispaniclatina and asian backgrounds the study revealed that women in traditional societies often carry symbolic representations of purity within their respective cultures however when they deviate from the established cultural norms they may face consequences such as ostracization restrictions or abuse all of which can destabilize family dynamics as a result these women feel immense pressure to adhere to societal expectations and may avoid seeking help from external sources in cases of intimate partner violence to protect family stability and avoid further threats a study that examined helpseeking by young arab women in israel found that they face three categories of barriers intraand interpersonal sociocultural and sociopolitical beyond the cultural reasons that prevent arab women from seeking help other barriers arise from belonging to a minority group in israel and the existing political conflict between israel and the palestinians some of these have to do with a lack of trust in the israeli authorities and with cultural and language gaps these sociopolitical difficulties may affect both the womens willingness to ask for help and the sources to whom they can turn the ways in which women choose the source of support and coping may change and vary between turning to official state agencies and agents of unofficial support like family and friends according to selestine et al for women who do decide to seek help selecting an appropriate source of support brings more challenges a study that examined helpseeking on a sample of 6589 american women who experienced domestic violence and compared women who were part of a social minority with those of a higher social status revealed that women who were in a social minority sought less help from state aid agencies another study examined the willingness to turn to informal sources of help compared to official sources on a sample of 152 indian women belonging to a social minority and found that most of them would prefer to turn to informal sources of assistance additional findings revealed that although women approach informal sources of assistance they do so with relatively low frequency because they fear that their status in the family will be harmed by contrast women who are not part of a minority are more likely to seek assistance in general mainly from official aid agencies because they do not encounter the barriers faced by minority groups hence arab women in israel are trapped on one hand they are afraid to turn to unofficial sources of assistance within arab society because they fear damaging the status of the family in the community on the other hand turning to formal authorities in israel is problematic because of the political complexity caused by belonging to a minority group the ability to seek help and gain access to sources of support is of great importance it is essential for mental health protecting a person from the effects of stress in the case of ipv the protection is not only for the persons mental state but often also for her life research objective this study examined the willingness of jewish and arab women in israel to ask for help in case of ipv the cultural differences between the sectors and the differences arising from being part of majority vs minority groups may affect their tendency to ask for help as well as the sources they choose to approach understanding these factors may help devise accurate and culturally appropriate interventions for each group taking into account and lowering the barriers that prevent seeking help hypotheses 1 jewish women will show a greater tendency to seek help than arab women moreover jewish women are more likely to seek help from unofficial sources whereas arab women are more likely to approach official sources that identify with their community 2 a positive correlation exists between the tendency to seek help and mental wellbeing 3 a negative correlation exists between the tendency to seek help and demographic variables methods participants seven hundred and ninetysix israeli women participated in the study including 357 jewish and 439 arab women participants ages ranged 1875 years years 495 of the participants were single 278 married and 23 widowed or divorced 414 defined themselves as religious 318 as traditional and 232 as secular an a priori power analysis was conducted using g power version 3197 to determine the minimum sample size required to test the study hypothesis results indicated the required sample size to achieve 90 power for detecting a medium effect at a significance criterion of α 005 was n 191 for each group for independent ttest thus the obtained sample size of n 796 is adequate to test the study hypothesis tools the study was based on a quantitative questionnaire consisting of three parts 1 demographic questionnaire including questions about the participants age religion level of religiosity and marital status 2 willingness to seek help questionnaire which asked participants if you were a victim of domestic violence whom would you be willing to tell about it participants were presented with a list of 11 options and were asked to mark on a scale ranging from 1 to 5 the likelihood that they would turn to each of them for help the list of options is shown in table 1 cronbachs alpha for the questionnaire was 082 3 mental health continuum short form the questionnaire consists of 14 items each one containing a statement describing mental wellbeing participants were asked to rate the frequency with which they experienced each item in the preceding month on a scale ranging from 1 to 6 examples of statements i felt that my life had meaning and purpose i felt i had a warm and trusting relationship with others cronbachs alpha for the questionnaire was 092 research procedure the study was approved by the university ethics committee the research questionnaires were administered to a convenience sample of jewish and arab women in israel in the course of 2022 although the sample was not a representative one it includes representation of participants from various areas in israel emphasis was placed on including participants from arab jewish and mixed localities the questionnaires were distributed in hebrew and arabic by research assistants from both communities through social networks participants were guaranteed that the survey was anonymous and that it was intended for research purposes only the participation in the research was voluntary we clarified to participants that there were no correct answers to questions and participants were asked only to express their opinions findings helpseeking in case of ipv confirming our first hypothesis ttests for independent samples revealed that there were significant differences between groups in the probability of seeking help for ipv and the probability of jewish women seeking help was significantly higher than that of arab women doing so table 1 presents the likelihood of seeking help from various sources by jewish and arab women in israel as shown in table 1 the rate of helpseeking by both jewish and arab women from firstdegree family members was not high about 30 would turn to their fathers with high probability and less than 20 would turn to their mothers or siblings for help but there were significant differences between the groups most jewish women indicated that they would turn to a friend whereas only 323 of arab women did so jewish women also indicated greater willingness to seek help from nonfirstdegree relatives than arab women did physicians or nurses and social organizations by contrast arab women indicated greater willingness than did jewish women to seek help from social workers and of religious leaders correlations between variables tables 2 3 concerning hypotheses 2 and 3 present statistics of the study variables and the correlations between them we examined the correlations between likelihood to seek help mental wellbeing and age using pearsons test and the correlations with the level of religiosity with spearmans correlation as shown in tables 23 and confirming hypothesis 3 the probability of seeking help correlated significantly with the sense of mental wellbeing the correlation was stronger in jewish than in arab women we found a significant correlation between the probability of seeking help in the case of ipv and the participants age with opposite trends between jewish and arab women for arab women we found a negative correlation in accordance with hypothesis 4 whereas for jewish women we found a positive correlation thus the younger arab women were the greater the probability was of their seeking help whereas for jewish women the probability of seeking help was higher for older women this finding may be explained by the level of religiosity of the participants contrary to hypothesis 4 for jewish women we found no correlation between the probability of seeking help and level of religiosity by contrast for arab women we found a negative correlation between these variables the significant correlation between age and level of religiosity of arab women explains why older women were less likely to seek help for jewish women the correlation between age and the level of religiosity was negative therefore we found no correlation between the level of religiosity and the tendency to seek help discussion ipv has many consequences for the physical and mental health of the victims one of the victims strategies for coping with ipv is turning to formal and informal sources for help the present study examined the tendency of jewish and arab women in israel to seek help in case of ipv the findings revealed a significant connection between the willingness to ask for help and the womens mental health the mere knowledge that the women have someone to turn to in case of violence appears to lead to better mental wellbeing an understanding of the barriers that women face in seeking help and of the entities they can approach for help can guide service providers in developing solutions that are culturally appropriate for each community in accordance with its cultural codes the findings of the study reveal that in general jewish womens willingness to seek help is significantly higher than that of arab women this gap originates in the differences between the two cultures although jewish society contains among other conservative groups and the differences between the jewish and the arab societies do not constitute an extreme dichotomy the jewish society is considered to be more liberal western and egalitarian than the arab society arab society in israel despite the change it is undergoing remains traditional collectivist and patriarchal arab culture expects women to be submissive subservient to men to uphold family honor and not approach actors outside the community the fact that israeli arab women are part of a minority group which has conflicts with the legal authorities reduces their trust in the authorities and the chance that arab women will approach either internal or external sources of help as noted arab society is in the process of transitioning from traditionalism to modernity the change includes urbanization structural changes in participation in the labor market and work patterns a rise in educational levels exposure to media and detachment from the extended family and traditional social institutions our findings indicate that there is a negative correlation between the age of the arab women and their willingness to ask for help with younger women being more likely to seek sources of support the change also reflects a willingness on the part of the women to extricate themselves from the cultural trap in which they are the women in both groups tend not to turn to their parents for help especially not to their mothers possibly they do not perceive the mothers as having sufficient social power to help them but there are differences between the groups in whom they approach for help as noted 627 of the jewish women stated that they would turn to a friend for help whereas only 323 of the arab women indicated that they would turn to a friend jewish women were also much more likely to seek help from nonfirstdegree relatives from a physician or nurse and from a social organization dealing with ipv by contrast arab women indicated that they would approach two sources of help more than jewish women would social workers and religious leaders this finding indicates the tendency of arab women to turn to formal authorities over the past decade there has been a notable rise in awareness among the arab public in israel regarding the urgency to establish programs aimed at preventing domestic violence consequently numerous organizations have emerged within arab society providing essential support services for women in many instances social workers within arab communities are arab women themselves which not only enhances accessibility but also helps to alleviate mistrust the tendency of arab women to seek help from external parties rather than their relatives attests to the sway of traditional culture which silences women victims cuestagarcía and crespo reviewed numerous studies showing that family reactions and womens fear about what their family members and friends might think acted as a barrier to helpseeking for example aburas found that arab immigrant women in the us showed fear of disapproval and of being stigmatized by their families for their decision to seek help shechtman et al explained the reluctance to seek help from parties in the community both by the social stigma and the selfstigma associated with it public stigma refers to the negative stereotypes that individuals perceive that their society maintains about those who seek help in previous studies public stigma has been associated with decreased helpseeking attitudes and intentions individuals internalize these stereotypes and attach negative attitudes to their selfconcept a phenomenon known as selfstigma which includes feelings of shame fear of losing selfrespect and isolation this explanation clarifies why the arab women in the present study are less likely to ask for help underestimated the ability of their mothers to provide support the choice to turn to official bodies provides women with protection and gives them the strength to face the social pressures in their community limitations the main limitation of the study lies in the fact that the women were not directly asked whether they had been victims of ipv the purpose of the study was to learn about the cultural and social differences in the helpseeking tendency between jewish and arab women therefore the study addressed the general population but it is possible that some of the women who participated in the study were ipv victims creating a bias in their answers moreover the study examined the womens perception of a theoretical case of ipv if you were a victim whom would you turn to therefore our results indicate an expectation of behavior rather than actual behavior external validity and generalizability the study examines differences between two population groups jewish and arab women two cultural groups differ from each other jewish society is more modern western and liberal whereas arab society is more conservative traditional collectivist and patriarchal although the differences between the groups are not necessarily dichotomous but rather on a continuum this study can be broadly generalized the research findings may be relevant to many societies that are in the process of modernization and change such as traditional immigrant communities living in western countries future research a followup study should be conducted among women who identify themselves as victims of ipv to examine whether they sought help and from which sources in addition it is important checking what influenced the decision to contact or not to contact a certain source prevention and policy implications both state agencies and womens organizations in israel have made attempts to raise awareness of ipv and encourage women to seek help in the case of victimization it appears however that cultural barriers significantly reduce the willingness to seek help this study shows that it is necessary to act with cultural sensitivity and adapt help options to the culture to which the women belong furthermore the understanding of the barriers facing arab women which result in low rates of help seeking within their community suggests the need to develop intervention programs that raise the community awareness of the difficulty of escaping the cycle of violence and offer an enabling place for receiving support to create a fundamental change it is necessary to start with educational programs from a young age in schools with the aim of encouraging solidarity against violence data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement the study involving human participants was approved by the ariel university ethics committee written informed consent to participate in this study was not required from the participants in accordance with the national legislation and the institutional requirements publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

objective intimate partner violence ipv has many consequences for the physical and mental health of the victims one strategy for coping with ipv is to turn to formal and informal sources for help the purpose of the present study was to examine the di erences in help seeking tendency in cases of ipv between jewish and arab women in israel and the connection to their mental healthwe administered a structured quantitative questionnaire to a sample of jewish and arab womenthe findings indicate that jewish women tend to seek help more often than do arab women and that there are di erences in the targets they approach jewish women turn more frequently to uno cial sources such as friends relatives and associations whereas arab women approach more often o cial sources such as social workers and clergywe propose an explanation for the di erences based on sociocultural factors this study illustrates that it is necessary to act with cultural sensitivity and adapt the help options o ered to the culture to which the women belong this adjustment may encourage more women to apply for support to escape the world of violencehelp seeking tendency intimate partner violence cultural di erences victimization support source mental health 2019 many studies that examined ipv in different societies and cultures found that it is present regardless of social class religion sector country or continent and it exists for many psychological and sociological reasons gilbar et al 2022 in the present study we argue that helpseeking in the wake of ipv like ipv itself is the product not only of individual psychological frontiers in sociology frontiersinorg neemanhaviv and shafran fsoc

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introduction stating that the internet has transformed our lives is a rather selfevident claim nowadays in the mid1990s some psychologists started to question whether this technological breakthrough could have a darker side as some individuals seemed to be getting overattached to the online world to the point of losing control over the use of the tool and experiencing conflict with other areas of their lives as a consequence these symptoms were according to young akin those of substancebased addictions hence she termed this phenomenon internet addiction the author developed a diagnostic tool inspired by the diagnostic and statistical manual of mental disorders version iv criteria of pathological gambling as a type of impulsecontrol disorder debates as to whether this maladaptive behavior should be called addiction are still ongoing as some argue that this can result in the trivialization of the devastating impact of substancebased dependencies moving from this debate we prefer the term compulsive internet use since this encompasses what many have agreed as the necessary defining factors control loss over the use and interpersonal conflict without the other connotations of addiction much of the early evidence on this phenomenon was based on highly exploratory survey studies often using unrepresentative samples and diagnostic tools with unknown psychometric properties whereas problems of underrepresentation are being increasingly overcome and more sophisticated theorydriven studies are being conducted there still remains a lack of agreement regarding the key constitutive elements of ciu which in turn affects the estimation of reliable prevalence figures most of the diagnostic tools to identify ciu are inspired by the criteria of pathological gambling from the dsm iv and therefore share the same key dimensions however methodological decisions regarding the estimation of thresholds have resulted in a wide variety of prevalence figures with the suspicion that the problem might have been overestimated a more fundamental conceptual matter is whether the aforementioned dimensions relate to actual maladaptive use or instead are measuring a form of healthy engagement with the tool from which positive consequences are derived in fact studies conducted by charlton suggest that items representing the aforementioned dimensions tap into two differentiated engagement and addiction factors and that these have different correlates since in contrast to addiction factor 1 engagement was found to be associated with positive consequences in view of this the first objective of the study was to examine prevalence levels in our sample of adults from the us and the uae applying charltons core criteria to a widely used and reliable measure of ciu these findings are expected to contribute to the dissemination of more rigorous prevalence figures to avoid potential overestimation of the problem since previous studies have analyzed the drivers of ciu in relation to overall ciu which potentially mixed a range of engagement and core ciu dimensions our second objective was to identify how individual differences wire people to be more vulnerable to this maladaptive use of the internet focusing on the core dimensions of the compulsive diagnostic tool for this we built on daviss model of diathesis and stress according to which there need to be previous psychopathological issues access to the tool and a lack of social support these conditions result in a series of maladaptive cognitions about the self and the world that predict maladaptive internet use building on studies that report a strong link between low selfconcept clarity and social anxiety in facetoface contexts we expected this trait to be particularly central in predicting a persons likelihood to make up for the difficulties of facetoface interactions with online encounters importantly we argue that at low levels of social support and in line with the importance that daviss model gives to the social aspects selfconcept clarity would be a key vulnerability factor of ciu thus our third objective was to test the extent to which scc is associated with core ciu at low levels of social support while controlling for neuroticism and distorted cognitions previously identified as powerful drivers of ciu finally since the impact of selfconcept clarity on individuals wellbeing seems to be more relevant in western cultures our final objective was to confirm that the relationship between scc and ciu in our representative of eastern culture would be weak in contrast to that in the western sample measuring prevalence compulsive internet use engagement or both instruments evaluating compulsive internet use are largely inspired by the diagnostic classification of pathological gambling in the dsm iv and griffithss review of browns hedonic management model although these tools may use different sets of items they converge around the constitutive elements of the problem these are cognitive salience tolerance behavioral salience withdrawal symptoms relapse and reinstatement and loss of control and conflict with regard to the dimension of euphoria there is some disagreement griffiths and meerkerk called this dimension mood change as they argued that rather than seeking a high quite often individuals were looking to be immersed in the activity most prevalence studies pertain to teenagers yet some prevalence figures for adults have been released these vary considerably 144 of german adults 30 of japanese adults 84 of young british adults and 61 of british adults although the different tools to assess ciu converge in the conceptualization of the aforementioned dimensions part of this variety may come from using different items in their chosen scale to assess the supposedly same dimension another important source of disparity is the scoring mechanisms that have been used to confirm a positive diagnostic the first system corresponds to the dsm ivinspired schemes which estimate figures either by confirming a number of items endorsed out of a given total or by reaching a total average score above the equivalent of scoring frequent for each question in the scale the second system corresponds to browns nomothetic criteria according to which one should endorse all of the dimensions to be given a positive diagnostic charlton and charlton and danforth found that when this system was applied none and 17 respectively were diagnosed as compulsive users from their samples nevertheless charlton argues that this rather restrictive diagnostic system is far from reliable when applied to current tools which mix actual compulsive use indicators and those associated with a positive high engagement with the tool thus charlton and birkett found that their respondents seem to derive positive valued consequences from engaging significantly with their computers similarly steinkuehler and williams found significant social gains for highly engaged individuals with online gaming likewise shotton compared high users who could well fall into the supposed ciu pattern with normal users and found that the users reported improved reasoning and analytical skills technological knowledge and a range of positive emotional outcomes including selfesteem and lower depression in the light of these studies charlton ran factor analysis with the key dimensions of ciu measured through items developed in previous studies and their own scales of apathyengagement computer use they found two independent factors an engagement factor made of items measuring the dimensions of tolerance cognitive salience and euphoria and core compulsive use factor made up of withdrawal behavioral salience relapse and reinstallmentcontrol loss and conflict the author concluded that whereas tolerance cognitive salience and euphoria were clear indicators of high engagement none of these dimensions were related to negative consequences thus as opposed to behavioral salience where the activity dominates your life thinking excessively about the activity did not cause significant conflict with their lives according to grohol this characteristic of high engagement is in fact a phase through which anyone trying a new technology may go and this eventually wears off for the majority beard and wolf also argued that having the idea always on your mind and wanting to use the tool for longer every time were still signs of a likely healthy high engagement the twofactor model resulting from the factor analysis of the common dimensions used to diagnose ciu was confirmed in a further study with game users further evidence was provided by a later study which supports that these dimensions have different antecedents and consequences with the compulsive factor being more strongly associated with the big five trait of neuroticism charlton and danforth also found that the two factors differ significantly in relation to the time spent online with those endorsing core compulsive criteria reporting an average of two days more than those who were classified as engaged in view of the evidence gathered in these studies charlton and danforth recommended addressing the issue of overestimation by including only the core dimensions of compulsive use in future prevalence studies in view of this evidence a third alternative to measure prevalence and one that would be less likely to overestimate the scope of the problem is one where only these core compulsive features are included for a positive diagnostic using these compulsive use indicators and replicating previous threshold agreements for comparison purposes charlton found that 62 of those classified as addicted in his sample would have been attributed the label only by endorsing the engagement criteria similarly charlton and danforth found 10 fewer people classified as compulsive users when estimating prevalence with the core criteria as opposed to when they included the engagement items too in view of this we expect that once charltons core ciu criteria are applied to the measure of ciu developed by the widely validated measure of meerkerk et al the levels of prevalence will be significantly lower than when evaluating prevalence with all of the items in the scale as this contains high engagement items too hypothesis 1 prevalence of compulsive internet users with meerkerks original scale and cutoff limit is significantly higher than prevalence estimated with charltons criteria diathesisstress model of compulsive internet use browns hedonic management model states that we all seek activities that help us experience pleasure in our lives the difference between this selfmanagement and motivational process and the development of addictions lies in individual vulnerabilities in particular brown argues that the excessive appetite for the behavior results from restricted access to other related sources of reward hence they will be more likely to engage in hedonic tone manipulation with the particular object of addiction a useful framework to identify these vulnerabilities in relation to generalized ciu is daviss cognitivebehavioral model the term generalized is used to distinguish from other compulsive behaviors for which the internet is only the channel that materializes the drive importantly daviss model states that the unique aspect of this generalized ciu is that it provides the perfect environment to meet a social need in those individuals who lack social support and struggle to maintain healthy and adaptive social interactions in the facetoface world hence the internet becomes the alternative reward source for that social need the model also posits that underneath the social struggle individuals present an underlying psychopathology related to social anxiety andor depression which manifests itself through distorted cognitions about the self in relation to their social environment in short the diathesis combined with restricted social support becomes a key driver of the compulsive internet use regarding underlying psychopathology factors the big five broad trait of neuroticism has been often studied in relation to ciu as a proxy for depression and anxiety studies suggest however that this variable is far from a consistent predictor of ciu as some studies find it unrelated to compulsive internet use building on the emphasis that davis puts on vulnerability factors associated with ones social world individual differences more closely related to how an individual interacts with hisher social environment are more likely to be powerful explanatory factors in the development of the condition in particular a personality trait that is associated with distorted cognitions about the self as well as the underlying psychopathology of social anxiety is selfconcept clarity campbell et al define scc as the extent to which the contents of selfconcept are clearly and confidently defined internally consistent and temporally stable a related aspect of the selfconcept is selfesteem which includes the actual content and evaluation of the selfconcept itself whereas scholars have associated selfesteem with different wellbeing indicators they have paid less attention to structural aspects of the selfconcept nevertheless scc explains further and unique variance in psychological adjustment coping style stress and wellbeing of particular relevance for the cognitivebehavior model used in this study is the way in which selfconcept clarity can affect wellbeing through its impact on ones interaction with ones social world according to campbell et al low selfconcept is associated with higher sensitivity to social stimuli and a higher level of social comparison in fact a strong association between low scc and pathological social comparisons has been confirmed even when controlling for depressive symptoms furthermore evidence suggests that low scc may cause impairment in a variety of functional social interactions with studies suggesting greater difficulty in conflict resolution cooperative problem solving and romantic relationship success it would seem that lacking a stable set of beliefs with regard to oneself impedes adaptive social transactions as individuals are anxious about disclosing their fractured selfconcept to others in fact researchers have found that the lack of scc is an antecedent of social anxiety in facetoface contexts thus wilson and rapee concluded that low scc was a key predictor of social phobia beyond the effect of depressive and anxiety symptoms similarly stopa et al also found selfconcept clarity to predict social anxiety in a sample of undergraduate studies beyond selfesteem and depression in short a disintegrated selfconcept could significantly impair individuals adaptive relationships with others which further impedes clarifying their selfconcept virtual interactions constitute a unique social context where individuals have a much lower reliance on appearance and can conceal aspects of the self with which they are less comfortable this of course varies with the extent to which they engage in completely virtual interactions with people whom they have never met before or if it is a virtual interaction with offline acquaintances even then studies suggest that there is a high degree of selfediting properties that have no parallel in our facetoface social world the hyperpersonal theory of communication suggests that these features of the virtual space stimulate the development of deeper and more meaningful relationships potentially enhancing selfimage and positive identity building in view of the opportunities to protect the undesirable aspects of the self in virtual interactions we argue that individuals with low scc are likely to perceive this context as a safer environment to meet their social needs this however could potentially result in undesired effects as israelashvili et al reported a significant association between low scc and ciu in teenagers indirect support for this has also been found in teenage groups thus social phobia has been linked to compulsive internet use in teenage groups and as argued earlier social phobia seems to be strongly linked to scc since extensive evidence supports the theory that scc also plays a key role in wellbeing throughout adult life a significant relationship between scc and ciu in adults could be expected notwithstanding daviss model suggests this predisposition is likely to interact with social support factors in predicting ciu social support involves the necessary presence availability and quality of stable human interactions meaningful others who can offer help and support if needed feelings of available social support are considered a natural resource that increases levels of a hormone called oxytocin which has soothing and calming effects on the experience of distress because of these properties social support can play a key role in the prevention of and recovery from addictions regarding ciu charlton found that the key condition that would move individuals from high engagement to compulsive use was their perception that facetoface interactions were problematic or nonexistent in view of this we expect that when individuals perceive low levels of social support the relationship between selfconcept clarity and ciu is strong and negative in contrast when levels of social support are high we expect the salience of socialrelated traits to be less relevant than personal preferences for online interactions and other general personality traits associated with underlying psychopathology of anxiety and depression importantly the relationship between selfconcept clarity and wellbeing seems to be culturally bounded in western cultures the normative view of the self is an integrated set of components that remain relatively stable across time and situations human behavior has been conceptualized within a highly individualistic view of the person independent from others and highly unique and this in turn influences how a person sees himself and his selfconcept markus and kitayama labeled this concept independent selfconstrual and it is often associated with people in individualistic cultures in contrast members of eastern cultures tend to have a more collectivistic view about the self and others and are more open to the influences of the external environment in the way the self and identity are constructed hypothesis 2a selfconcept hence individuals from these cultures are more likely to exhibit interdependent or relational selfconstrual as they think of themselves as part of a broad interconnected network because of these characteristics individuals in these cultures are likely to be more tolerant of potential inconsistencies in aspects of the selfconcept regarding time or situation variability importantly these differences influence the impact that a lack of stability in selfconcept has on wellbeing thus in a study conducted by campbell et al the authors found that selfconcept clarity was more weakly associated with individuals positive evaluation of themselves in an eastern country as opposed to western countries where these associations were stronger other studies have also confirmed weaker associations between scc and different wellbeing indicators in eastern and high relational selfconstrual countries compared to western or independent selfconstrual countries most of the evidence supporting these claims has been gathered with east asian studies though there is evidence that middle eastern countries such as the uae or lebanon also exhibit a more relational selfconstrual the uae is a middle eastern country which has been understudied in relation to the compulsive internet use in adults and the values of its society stem mainly from islam and arabic tradition although uae citizens amount to approximately 20 of the population immigrants come from other eastern countries ie arab and iranian 23 south asian 50 with a smaller proportion of europeans and americans at 8 building on the idea that individuals from the uae are likely to exhibit more interdependent selfconcepts and therefore more likely to tolerate lack of stable selfconcept across time and situations we expected that the relationship between scc and ciu would be rather weak because of the complex composition of this countrys population and to avoid the culture fallacy we decided to control for collectivist values which are a proxy for relationshipfocused selfconstrual hypothesis 4 the relationship between selfconcept clarity and core compulsive internet use in the uae sample is weak materials and methods participants and procedure we gathered data with an online survey administered through a large market research company with local panels in over 37 countries the chosen countries were the us and the uae we selected respondents whose age was between 18 and 65 and we required balanced samples in terms of gender although the uae sample contained a slightly higher percentage of male respondents the market research company that we used for data collection specializes in offering panels for crosscultural research and provides panelists who broadly reflect the population of the country in question a key requirement to be a panel member was to be a resident of the given country it is important to consider that the uae has a high level of expatriates from other countries though these are mainly from eastern countries which are traditionally considered collectivist cultures this unique characteristic of the uae population was equally reflected in our panel composition nevertheless since the key requirement for the hypothesis was to hold more collectivist values we included a measure for collectivism and confirmed that our uae sample held significantly higher collectivist values than the us sample 241 p 05 us respondents spent an average of 323 hours outside work online whereas in the uae they spent 254 hours and this difference was highly significant 343 p 001 when asked about the main source of social support nonvirtual friends including family showed the highest percentages in both countries closely followed by work colleagues and finally virtual friends or none we also asked the preferred channel to interact with the main source of social support for minor problems in uae we found that whereas 54 of people still preferred to discuss these matters face to face the rest would do so using the phone or by instant message for major problems the face to face percentage increased to 76 this was similar in the us with minor problems being 51 and major problems 73 instruments selfconcept clarity we used campbell et als selfconcept clarity scale this is a 12item scale on the 5point likert scale ranging from 1strongly disagree to 5strongly agree a sample item is my beliefs about myself often conflict with one another cronbachs alphas were 84 for the us and 87 for the uae compulsive internet use we used meerkerk et als compulsive internet scale which consists of 16 items and respondents answered each of the items on a 5point likert scale from 1never to 5very often a sample item was how often do you feel depressed or irritated when you cannot use the internet the cronbachs alpha for the scale was 95 for the usa and 94 for the uae as discussed in section 2 we followed charltons theoretical model and only included the dimensions of the construct that tap purely in the core compulsive factor cronbachs alpha for the core ciu was 82 for the us and 75 for the uae please insert table 1a preference for online social support we used three items from caplans preference for online interaction scale here we asked respondents to rate the extent to which they agree or disagree with each statement on a likerttype scale ranging from 1strongly disagree to 5strongly agree a sample item was online social interaction is more comfortable for me than facetoface interaction the cronbachs alpha for this scale was 89 for the us and 81 for the uae social support we used rena et als 5point likert scale it ranges from 1never to 5very often a sample item was do you have someone to confide in or talk to about your problems the cronbachs alpha was 85 for the us and 83 for the uae control measures we used the fouritem subscale of neuroticism from the miniipip and we rated the statements on a 5point likert scale the cronbachs alpha for neuroticism was 69 for the us and 60 for the uae we also controlled for individually held values about collectivism with the 6item scale from yoo donthu lenartowicz and cronbachs alpha was 87 in both countries data analysis in order to test hypothesis one we estimated prevalence levels following different methods first we followed the ciu scale developers recommendation to establish the threshold on the overall score of someone who would select more than sometimes for each item in the scale we then used charltons framework according to which the core addiction dimensions were withdrawal conflict loss of control and cognitive salience this resulted in the use of 9 out of the total 16 items second we followed a system commonly used by those inspired by the dsm iv cutoff criteria thus we attached a positive diagnostic to compulsive users those who endorsed more than half of the items the endorsement criteria were attributed through the dichotomization of item scores and we used two different criteria first a less conservative one akin to meerkerks suggestion of using responses from sometimes upwards and second a more restrictive one admitting an endorsed item if individuals rated the statement from often upwards subsequently and given that some of our subjects would be duplicated in each group we used mcnemars paired proportions method to test hypothesis 1 please insert table 1b the remaining hypotheses were tested with structural equation modeling and amos 20 software since we used samples from two countries we first conducted multigroup confirmatory factor analysis to confirm metric invariance of the constructs we then tested the structural model separately for each country to allow us to test the moderation effect of social support with mgcf we used the median split method which consists of estimating the median of the continuous variable and using it to dichotomize the given continuous variable running mgcfa to test the relationships between the variables at the two levels of the moderator and evaluating the differences in chisquare between a model that allows a free path from scc to core ciu and a fully restricted model we estimated model parameters with maximum likelihood and used various goodnessoffit indices to assess the models fit these were chisquare statistic divided by the degrees of freedom the comparative fit index the root mean square error of approximation and the standardized root mean square residual the  2 df ratio must be below 3 the value of cfi should be above 9 and the values of rmsea and srmr below 08 results prevalence analysis the resulting prevalence estimates following the three methods described in 43 can be appreciated in table 1b mcnemar test was significant for the comparison of compulsive users proportions estimated with meerkerks criteria and that estimated with charltons in the usa and the uae expectedly these differences were also significant when comparing meerkerks criteria to charltons more stringent one hence hypothesis 1 was supported moderation analyses please insert tables 2 3 first we present the bivariate correlations between the variables of study for each country our main construct of study seems to be significantly associated in both countries in order to test hypothesis 2 with sem we developed a latent variable model and the indicators of each latent variable and their respective factor loadings can be appreciated in table 3 since we had samples from two different countries we conducted measurement invariance tests first we fitted the model with the hypothesized relationships to the two groups in the us and the uae the baseline model showed good fit supporting basic configural invariance we then constrained the loadings of the latent variables to be equal across the two samples in order to test for metric invariance given that the comparison of the models was not significant 2252 ∆df24 p285 metric invariance was also supported hence we could assume that the instruments were not measuring different constructs across the two national groups we then tested the quality of the measurement model by confirming that all factor loadings in relation to their latent variable were well above 5 construct reliability and average variance extracted were respectively above the recommended threshold of 7 which further supports construct validity please insert tables 3 4 subsequently we ran mgcfa for people who scored high versus low for levels of social support using the split median method for each country the model fit for the moderation model in the us showed good fit constraining the path from scc to core ciu to be equal significantly harmed the model fit 3 p 05 suggesting that the two groups were significantly different the difference between these groups can be further appreciated in figure 1a where the low social support group showed a highly significant path between scc and ciu thereby supporting hypothesis 2a since we also confirmed that this relationship was significant in the presence of neuroticism and preference for online social interaction we also confirmed hypothesis 2b in contrast in the high social support group both neuroticism and poi showed significant paths hence hypothesis 3 was supported we ran the same analyses for the uae however the model constraining the path from scc to core ciu did not significantly show worse fit hence the equality constraint should be retained for parsimony purposes suggesting a lack of moderation effect in this country furthermore we also found that the association between scc and core ciu was only marginally significant at low levels of social support hence hypothesis 4 is partially supported as the relationships are even weaker than expected please insert figure 1a 1b discussion previous studies have offered a variety of figures regarding prevalence of ciu yet evidence suggests that most diagnostic tools are using systems that mix core ciu criteria with healthy engagement which could result in an overestimation of the figures following charltons framework we revised the ciu instrument and compared prevalence figures between the original scale with the criteria recommended by the authors and the core dimensions suggested by charlton we confirmed that the original recommendations overestimated the prevalence by at least 20 40 depending on the level of stringent criteria applied hence our results with the us and the uae samples expand charltons findings with general british samples and intensive game players in view of this we recommend a more careful consideration of the diagnostic tool and the dimensions included to avoid overestimating and labelling adapted individuals who obtain positive consequences from their high engagement a second objective of this study was to examine the vulnerability of falling into a pattern of compulsive hedonic management through the internet to meet unfulfilled social needs our findings lend support to and expand on daviss diathesisstress model according to which low access to social support interacts with underlying vulnerabilities related to social anxiety to predict ciu our final objective was to investigate whether scc and ciu would be weakly related in collectivistic cultures as opposed to individualistic cultures and our findings supported our hypothesis browns model of hedonic management applied to behavioral addictions suggests how these in a way are fulfilling a psychological function and could be conceptualized as the extremes of a continuum on selfregulation processes pathological forms of what otherwise would be routine hedonic management driven by individual vulnerabilities in line with daviss model previous studies have examined generic personality traits which showed some significant relationships in some studies however others found no significant relationship we argue that to some extent this could be due to the problem of engagement and core criteria being mixed in previous studies but also because a more complex interaction between social aspects and personalityrelated traits was to offer more sound explanations in this study we expand on daviss model by showing that when these needs are for social support those who have an inability to engage in healthy interactions owing to unclear selfconcept are more likely to develop an excessive appetite for this behavior as it provides opportunities to overcome those difficulties interestingly we also found that at high levels of social support selfconcept clarity becomes unimportant whereas ones preference for online social interaction and neuroticism become relevant predictors of ciu thus it would seem that when social needs are met the underlying predisposition to experience anxiety would make a higher contribution in explaining the development of the syndrome equally the significant association between preference for online interaction and ciu in both countries is in line with and expands on the study by caplan who found this variable to be a key predictor of ciu thus we argue that this is the case only when social support needs are relatively fulfilled as when this is not the case selfconcept clarity becomes more salient it is in those situations perhaps where this preference for online interaction could develop as in line with the hedonic management model online interactions would be satisfying an unmet need importantly our study also found that in the uae participants the association between scc and ciu at low levels of social support was rather weak thus in line with previous literature it would appear that in the independent construal sample the influence of lacking a clear and stable selfconcept is more important for wellbeing than it is for those with a more interdependent selfconstrual in the past crosscultural studies solely based on the dimensions identified at national level have been criticized because they ignore the extent to which individuals hold the values of their country of origin thus in a study conducted by brotheridge and taylor the authors found that immigrants adopted the values of the current host country rather than their home country since the uae is a country with a high level of immigration and we wanted to compare the impact of scc on ciu in relation to the different selfconstrual attributed to easterncollectivist vs westernindividualist we measured and controlled for individually held values of collectivism in line with the expected the us held significantly lower collectivist values than the uae sample thus our findings are in this sense relatively robust and contribute to the limited literature on ciu in adult populations and in particular eastern adult samples limitations and future research the present study has nonetheless limitations that we would like to acknowledge first we used a crosssectional design thus we cannot infer causal direction of the relationships another limitation concerns generalizing the results as the participants were panelists from market research however owing to the widespread internet use in the us we are confident that these participants are not significantly heavier internet users than the general population a different case is that of the uae we do not expect participants to have been representative of the uae citizenry but representative of the unique makeup of this countrys population nevertheless individually held cultural values were controlled for hence our findings may not be representative of the uae but could be so of eastern samples as these seem to hold on average more collectivist values than western ones notwithstanding future research with other eastern countries would clarify whether these relationships persist furthermore though this study confirms vulnerability factors in the west we know less about the vulnerabilities in the eastern or highly collectivistic culture though it seems scc is not a key driver studies suggest that ciu does exist in the east therefore vulnerability factors need to be investigated further our model highlights the key role of socially related vulnerabilities and it is likely that this is also the case in the east yet in contrast to the selforientation focus of the west we argue that constructs that measure perceptions of lack of respect by the groups that shape ones identity could play a more significant role in these cultures another area that merits further research is the transition from engagement to addiction we recommend that experimental and diary study methodologies are employed in order to identify the drivers that push someone to move from engagement to compulsive internet use this should contribute not only to confirming the key dimensions required to estimate prevalence figures and develop more sound diagnostics but also to understanding how to prevent ciu conclusions in closing our results confirm daviss model regarding the crucial role of social factors and the interaction between these and underlying personality traits we expand on this model by putting the focus on a trait that in past research has been strongly related to social inadequacies in facetoface interactions thereby suggesting low selfconcept clarity individuals to be key contenders for virtual interaction attraction the findings somewhat conflict 3 11 core compulsive relapse and reinstatementloss of control 129 note items 15 and 16 do not belong to the original version of ciu they were added by authors please note that core compulsive is called addiction in charltons work

compulsive internet use ciu has been mostly studied among adolescents yet some studies reveal that this can be a problem for the adult population too the lack of agreement on diagnostic tools and cutoff points results in markedly different prevalence figures building on charltons 2002 distinction between core ciu and positive engagement dimensions the first objective was to confirm that prevalence figures including the core dimensions of ciu were lower than those including the engagement dimensions as well second building on daviss 2001 diathesisstress model we tested the role that selfconcept clarity scc and social support play in predicting core ciu in us subjects n us 268 finally we expected that because selfconcept clarity is mostly linked to wellbeing in western countries the association between this variable and core ciu would be weak in the eastern culture sample n uae 270 our findings confirmed that prevalence figures were 20 to 40 lower when including the core dimensions only and that scc is a key predictor of ciu at low levels of social support in the us we also confirmed that this is not the case in the uae future research opportunities to advance this study were discussed

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background the ebola outbreak in west africa 20142016 was unprecedented in scale extent and duration the international community was slow to step up its assistance in this global public health emergency and then faltered when its infection control management approaches clashed with west african realities 1 outbreak response evaluations have identified the need to better integrate social science intelligence 2 better collaborate with communities 34 more effectively draw on the strength of community health workers 5 and critically question the paradigm of western health systems which focus on imposing evidencebased solutions that lack external validity in affected communities ie they too often recommend actions that are inconsistent with ignore or violate traditional behaviours 6 while there appears to be a consensus now on what needs to be done how to achieve these goals remains a challenge ebola intensified preparedness programme in order to identify practical ways to enhance the capacity of health workers and influencers to develop and articulate local and sustainable ebola response control and recovery solutions for affected and not yet affected communities an ebola intensified preparedness programme was set up in 2015 this initiative was funded by the rockefeller foundation using its emergency funds and managed by connecting organizations for regional disease surveillance this approach worked in addition and alongside other initiatives such as those by the united nations and other international organisations these also included biomedical capacity support such as mobile laboratories by clinical research institutions the united states centers for disease control and the german robert koch institute to name just a few the coordination of various response capacitybuilding initiatives proved to be very challenging and an international interagency ebola communication coordination call was set up that was chaired by the us cdc the ipp contributed frequently to this interagency briefing and used other opportunities during meetings with specific agencies to share its approach and outcomes ipp brought together communitybased health shapers with specific experience from previous ebola outbreaks in uganda and dr congo 7 these shapers included a mix of health professionals community leaders journalists policy makers religious leaders and traditional healers who influence the narrative of infectious disease management risk communication and community outreach in their local and national environments a series of twoday training programmes to be held in different countries was designed for these shapers they worked in facilitated small interactive groups using analytical matrix tools to elicit and capture insights on the underlying assumptions perceptions and beliefs of infection control management in their communities and countries and identify ways to shift the agenda and narrative to a more peoplecentred and communitybased health paradigm the ipp analytic matrix tool was built on five action principles that were identified in a scoping meeting with selected shapers from eastern and central africa with firsthand experience during ebola outbreaks 7 • communitywork with communities not against them • communicationlisten and gain insights into community assets and needs develop respectful culturally sensitive twodirectional riskcommunication and awarenessraising approaches • capacity buildingbuild the capacity of local community leaders and local healthcare workers in case detection and management • coordinationbuild local multistakeholder networks which coproduce action plans modifyingadapting a generic response plan for their specific ebola preparedness contexts and out the ebola intensified preparedness programme that was funded by the rockefeller foundation there are no conflicts of interest in regards to this publication • cultureunderstand it as a key driver of community resilience and as a potential enabling or limiting factor to infection control building on these principles the ipp workshops were organised around a series of key questions risk communication and risk management • risk managementwhat specific considerations need to be taken on the local community level for infectious disease management in small medium and largescale outbreaks • risk communicationhow can we frameshapebroaden communication to reflect different conceptions and perceptions of risks and respect the cultural drivers of communities • how can we ensure that risk communication is not only about giving health messages but also includes listening to and understanding local concepts and beliefs and works towards building relationships with communities to create supportive environments where people build their skills and make good decisions infection control • what are the specific infectioncontrol training needs at different levels of the community how can coordination with international organisations best be organised collaboration • how can we strengthen generic response plans that build on existing infrastructures • how can we encourage networking that effectively and efficiently shares information and expertise and develops sustainable collaborations between stakeholders this article reports on the outcomes of the first ipp held as a pilot training in kampala results pilot training ipp kampala the pilot training in uganda kampala resulted in a series of practical action insights and recommendations on ways to frame and promote the use of communitybased outbreak response to bolster current approaches to infectious disease management and recovery on all levels findings are presented here as key recommendations and short video narratives by participants explaining the points made the training was attended by participants from uganda burundi zambia mali dr congo kenya zimbabwe ghana and tanzania training workshop insights recommendations and video narratives change perception and confidence from victims to active protagonists the most striking insight was a shift in the way participants perceived and understood the scope of their roles as protagonists champions and leaders of communitybased infection control management at the beginning of the workshop participants described the situation of ebola preparedness response and recovery in dont have narratives these narratives emphasised and bemoaned problems resulting from deficits in resources the lack of scientific understanding of the disease in the population and poor communication between health professionals international aid workers and communities during the interactive work in small working groups this perspective shifted into new powerful action narratives these emphasise active wholeofcommunity ownership leadership and management of health healthcare and supply system logistic approaches to ongoing infectious disease challenges 8 in articulating these new approaches participants drew on evidence from previous ebola outbreaks and their firsthand experience and stressed the pivotal but poorly acknowledged role that communities play in limiting the spread of and controlling the disease 8 shift the focus of community engagement from telling to listening from formal leaders to informal leadership traditionally community engagement approaches are often limited to better explaining to local people what they have to do and how to better apply infection control recommendations participants elucidated mismatches with this conventional topdown approach to infection control which they felt did not truly acknowledge the resourcefulness and strength of communities and too often missed critical actionenhancing insights 9 participants pointed to and analysed examples of information sharing and communication that was too focussed on official scientific information and official community leaders and ignored informal communication and leadership systems of communities international recommendations and behaviour advice were seen as frequently inadequate insensitive and patronising adequate explanations were often missing and recommendations ignored the critical identitybuilding social and religious forces of societies 10 participants argued for more inclusive collaboration and participatory actions that eliminate the barriers between we and they they advocated for a better mutual understanding and the need for negotiating valid compromises to limit the spread and control the disease they pointed out for example that communities are able to modify their cultural or religious practices to reduce risk and create safer environments but these modifications have to be framed in ways that take account of local reasoning and what matters for both communities and infection control 11 shift power to the people participants criticised the international development and deployment model as cementing dependency on international aid while acknowledging that there are huge capacitybuilding needs and demands in regard to education training and professional development participants stressed that these have to be built on local terms assets needs and conditions international aid is too often designed to please the senders but does not meet the local needs they saw a discrepancy in the priority setting of the response while the international community engaged along the scientific medical rationale in vaccine production and clinical trials participants stressed the important but underestimated role of psychosocial support needs 12 realising the beauty of the ebola legacy communitybased one health participants suggested that response control and recovery all needed a much broader approach in which health is only one of the relevant sectors for improvement they called for a strengthening of communitybased one health approaches that include sectors such as trade travel research etc the beauty of ebolas legacy is seen as creating a unique opportunity to build and strengthen health and importantly local health supply systems according to local needs and wishes limiting or terminating the dependence on international aid would require strengthening local resources this would require supporting local economies to develop local solutions however as sectors are still underdeveloped they need to join forces with other disciplines and sectors on all levels and collaborate participants envisioned organising regional meetings with local stakeholders to build networks engage with industry and create business fora for innovation 13 conclusion participants suggested a much broader and more creative approach to response management and recovery they engaged in socioeconomic and political thinking about ownership confidence and independence that could support both the shortterm crisis management and longerterm resilience and capacity building in the region they called for a kampala manifesto that shifts power to the people and promotes a communitybased one health approach rollout of the pilot trainees of this pilot training joined cords staff in holding further ipp trainings throughout 2015 in affected and not yet affected countries in africa in total over 100 multipliers and trainers were directly involved training delivered by pilot trainees and other incountry trainers were held • 1314 january 2015accra ghana with participants from guinea ghana and burkina faso • 34 february 2015nairobi kenya with participants from south sudan kenya burundi tanzania and malawi • 1718 february 2015conakry guinea with participants from guinea liberia sierra leone togo and senegal bilingual formal analysis petra dickmann investigation petra dickmann methodology petra dickmann franklin apfel writing original draft petra dickmann writing review editing andrew kitua franklin apfel nigel lightfoot

international activities to respond to the ebola crisis in west africa were mainly developed and focussed around the biomedical paradigm of western health systems this approach was often insensitive to societal perception attitude and behavioural determinants and clashed with communitybased health traditions narratives and roles eg of community health workers in this peerled capacitybuilding initiative these deficiencies were identified and analysed innovative more locally focussed communitybased solutions were articulated the new approaches described put local people at the centre of all preparedness response and recovery strategies this paradigm shift reframed the role of communities from victims to active managers of their response and reacknowledged the strength of communitybased one health we conclude that strategies should aim at empowering not just engaging communities communities can improve shortterm crisis management and build longerterm resilience and capacities that are much needed in the current global health climate

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compared to 33 of students at fouryear institutions report receiving pregnancy prevention information 3 with such limited resources it is no surprise that community college students in some areas of the country are twice as likely to become unintentionally pregnant after enrolling in college compared to the average fouryear college student 1116 gender differences sexual risk behaviors often differ by gender 17 for example 1824yearold male college students at both traditional fouryear and twoyear institutions tend to have had more lifetime sexual experience and a higher number of casual partners than their female counterparts 13 men are also generally more likely to engage in risky sexual behaviors 18 including intoxicated sex 1920 while some gender differences may be attributable to biological factors the social environment plays an influential role as well gender norms the standards or expectations that a dominant culture assigns to men and to women respectively also influence behavior an example of a gender norm is the expectation for young men to act brave strong or aggressive while young women are expected to be polite demure or nurturing some adolescents may follow gender norms in order to be accepted by their peers but gender norm adherence can also lead to lower selfesteem and perceived pressure to engage in stereotypical gendered behaviors 21 including risky or unsatisfying sexual behaviors 22 while gender differences in risktaking have been wellstudied among fouryear college populations it is unclear if these findings are generalizable to community college students theory of reasoned action in addition to considering gender differences health behavior theory must also guide the study of sexual risk behaviors the theory of planned behavior proposed by ajzen as an elaboration on fishbeins theory of reasoned action is a relevant tool for measuring the constructs and factors that influence risky behavior the combined theory of reasoned action and planned behavior posits that attitudes perceived norms and perceived behavioral control contribute to intentions to perform a behavior 2324 there have been other adjustments and evolutions to tra tpb while knowledge was not originally included in tratpb it was later added in the early 2000s to create the integrated behavioral model 23 tratpb and the integrated behavior model have both been successfully applied to predict behavior change related to sexual risktaking 232526 social norms theory has also grown out of tratpb and suggests that higher perceived rates of sexual activity in peers increases the likelihood an individual will engage in sexual risk behaviors themselves 27 according to tratpb intention is a strong predictor of actual behavior and can be used as a proxy for predicting future behavior when true behavioral measures are unavailable 2328 models for behavioral intention are based on an assumption of rational choice otherwise known as valueexpectancy theories however these theories do not fully explain decisionmaking for arousalassociated behaviorswhen there is momentary temptation or arousal adolescents may be guided more by whim or impulse than by reason 29 despite these limitations there is still great value in applying these theories to measure risk numerous recent metaanalyses have found that tratpb is still a relevant efficacious theory that can help to predict and explain sexual risk behaviors 2526 the current study older adolescents enrolled in community colleges are at high risk for poor sexual health outcomes this population is underserved and underrepresented in research a gap which this paper attempts to address while trieu bratton marshak 11 conducted a preliminary examination of risky sexual behaviors in community college students their sample included only heterosexual students who were already sexually active the present study includes students who identify as sexual minorities as well as students who are not yet sexually active it also focuses exclusively on older adolescents aged 1819years old a time of rapid romantic and sexual development 30 this article presents an exploratory study of community college students designed to assess the prevalence of sexual history and current behaviors and identify factors that are associated with intentions to engage in risky sexual behaviors in the future the results of this study can inform future educational policy and health promotion endeavors by helping to prioritize intervention targets and identify subgroups of community college students at high risk for negative health outcomes methods procedures the authors performed an analysis of secondary crosssectional pretest data collected in an irbapproved randomized controlled trial which was conducted to examine the effectiveness of an online sexual health program for community college students the original efficacy study used a convenience sample from eight community college campuses representing four urban and four rural counties in one state in the southeastern us inclusion criteria were defined as being 18 or 19 years old and being enrolled as a community college student at one of the participating campuses exclusion criteria included not being fluent in english or not having access to a smartphone or tablet 31 measures background characteristicsdemographic characteristics participants responded to questions about how they identify according to their race ethnicity gender sexual orientation and religious affiliation pell grant eligibility was used as a reliable measure of socioeconomic status 3334 in the analyses the variable on pell grant eligibility was dichotomized as 0 students who were not eligible or did not know their eligibility and 1 students who reported that they were eligible information was also collected on relationship status asking students to report if they were in a committed dating relationship single married separated or divorced students were also asked to report their sexual orientation for the variable on sexual orientation all results are reported in table 1 for the analysis sexual orientation was dichotomized to 0 heterosexual 1 students who identified as gay lesbian bisexual asexual queer or unsure students also reported the highest level of education achieved by their parents for the analysis the variable for parent education was dichotomized to 0 neither parent obtained a college degree and 1 one or both parents had a college degree or more sexual history students were asked about their previous sexual experience and whether they had used a condom during their last sexual encounter selfreported data were also collected on whether participants had ever contracted an sti had ever been formally tested for an sti or had ever received the hpv vaccine sexual assault and abusive relationships students reported whether they had experienced unwanted sexual touching or if they had experienced unwanted penetration within the last 12 months participants also selfreported past 12month involvement in a physically or emotionally abusive relationship outcome of interestintentions to engage in risky sexual behavior an additive risk index was used to assess the selfreported likelihood for a participant to engage in a range of risk behaviors in the next six months the questions were adapted from existing measures 3536 the risk behaviors examined included having sex with a casual partner having sex with someone of unknown sti status going out with the intent of having sex leaving a party or social event with someone they had just met using alcohol or drugs before or during a sexual encounter having sex with someone who had multiple sexual partners in the past having sex with someone who was engaging in sex with others during the same time period and having sex themselves with multiple sexual partners during the same time period each of the eight questions had a 4item likert response scale cognitions related to sexual healthintentions to communicate with a partner intentions to communicate with a sexual partner about stis and pregnancy was assessed using fiveitems 3536 the question stem was if you were to decide to engage in sexual activity with a new partner in the next six months how likely would you be to… examples of items include talk with a partner about hivaids or other stis talk with a partner about a pregnancy plan or talk with a partner about past sexual partners each of the questions was rated on a 4point likert response scale intentions to get tested for stis one item captured students intentions to get tested for stis if you were to decide to engage in sexual activity with a new partner in the next six months how likely would you be to get tested for stis the question had a 4point likert response scale and for the analyses it was dichotomized such that 0 very unlikelyunlikely and 1 likelyextremely likely selfefficacy to use a condom one adapted selfefficacy question 35 assessed participants confidence in their ability to use a condom students responded to the statement i can use a condom correctly or explain to my partner how to use a condom correctly the question had a 4point likert response scale for the analysis this was dichotomized to 0 strongly disagreedisagree and 1 strongly agree agree perceived gender norms five items 36 assessed normative beliefs about gender roles example items include raising children is primarily a womans responsibility and a man who cries in front of a woman is making a fool of himself participants were asked to indicate how much they agreed with each statement on a 4point likert response scale descriptive norms around sexual behavior four items assessed perceived peer behaviors around sexual activity 37 students estimated what percentage of people their age were having sex had unprotected sex at last intercourse had sex with a casual partner and had sex while high on drugs or while intoxicated knowledge participant knowledge of sexual risks and protections was assessed using the knowledge of sexual risk and protection questionnaire 38 consisting of 23 factbased multiple choice questions items included how can someone get an sti and true or false you can tell if someone has an sti by looking at them correct responses were summed to derive a total knowledge score overview of statistical analyses basic descriptive statistics were calculated to assess sexual history and current behaviors an anova was performed to confirm that the outcome of interest intentions to engage in risky sexual behavior did not differ significantly across the eight campuses where data were collected because there was no significant difference across campuses a multilevel model was not required in the main analyses both bivariate and multivariate linear regression models were used to assess which factors were associated with intentions to engage in risky sexual behaviors the outcome of interest was considered approximately normally distributed due to the exploratory nature of this study the authors developed different multivariate models and presented the most satisfactory model here first bivariate linear regression was conducted between each predictor and the outcome of interest based on the results from these analyses a multivariate model was built predictors that were nonsignificant in the bivariate model or that had very low adjusted r 2 values were not added to the multivariate model unless they were deemed to be theoretically relevant and important to the outcome variable model parameterization was determined using the contrast statement in sas which quantified if a particular variable or set of variables improved model fit for example adding the race variables as a block did not significantly improve model fit therefore they were excluded from the adjusted model for the regression models the race variable was dummy coded so that students who identified as white were compared to all others in the sample those who identified as multiracial were separated into their own group to create mutually exclusive categories while students who identified only as asian american indian or pacific islander were not examined separately due to small numbers the gender variable was binary including those who selfidentified as male compared to those who selfidentified as female the number of students who selfreported as trans gender queer or gender questioning was too small to be examined in separate analyses and those students were therefore excluded from the bivariate and multivariate models due to missing values in the outcome variable and the binary gender variable the final analysis dataset consisted of 240 participants results descriptive statistics explored the sexual history and sexual health practices of this sample of community college students over twothirds of the participants reported previous sexual experience of those who had ever had sex the majority had engaged in vaginal sex and oral sex about a third of sexually active students reported that they had ever had anal sex for those engaging in vaginal or anal sex about twothirds of students reported using a condom during their last sexual encounter the lowest rates of condom use were reported by female students during their last experience of anal sex where only a quarter said that the penetrative partner had used a condom a small fraction of students reported having ever had an sti although only a third of sexually active male students reported they had ever been formally tested for both males and females a slightly higher proportion of students had received the hpv vaccine than had ever been tested for stis less than half of females and only a third of males in this sample had received the hpv vaccine most students said that they had never talked with a medical professional about sex contraception or romantic relationships table 4 shows the reported experience with sexual assault and abusive relationships within the last 12 months notably one out of every ten men and one out of every four women reported having been touched sexually without consent or having experienced an attempt at sexual touching without consent three percent of men and 10 of women reported having experienced rape or attempted penetration without consent in the last year experience with being in a physically abusive relationship was reported by 4 of men and 8 of women while emotional abuse within the last year was reported by 8 of men and 20 of women bivariate and multivariate linear regression models examined predictors of community college students intentions to engage in risky sexual behavior gender was significantly related to intentions to engage in risky sexual behaviors in the unadjusted model such that male students had higher intentions to engage in risky sexual behaviors than female students after controlling for other covariates gender was still significantly associated with intentions to engage risky sexual behavior no other demographic variable including parental educational attainment pell grant eligibility sexual orientation or race were significantly associated with the outcome the was associated with greater intentions to engage in risky sexual behaviors in the future this association remained strong even after controlling for covariates in the adjusted model in both the adjusted and the unadjusted model less intention to communicate with a sexual partner about stis and pregnancy prevention was associated with higher intentions to engage in risky sexual behaviors furthermore greater endorsement of traditional gender role norms was associated with higher intentions to engage in risky sexual behavior according to the models sexual health knowledge intentions to get tested for stis and selfefficacy to use a condom were not associated with intentions to engage in risky sexual behaviors perceived peer norms around sexual activity and risktaking however were close to the significance threshold for an association with intentions to engage in risky sexual behaviors for both adjusted models the adjusted r 2 value was 021the models account for approximately 21 of the variability seen in intentions for risky sexual behavior in both adjusted models gender and having had sex previously had the highest beta weights and therefore are likely the most influential independent variables in the model the second adjusted model determined that the effect of sexual health knowledge on intentions does not differ significantly for male students compared to female students by adding this interaction term the coefficient for gender increased from 231 to 859 the second adjusted model suggests that on average female students in the sample scored lower on the additive risk index for intentions to engage in risky sexual behavior by 859 points compared to males while holding all other variables constant including the interaction term comment this paper examined the sexual health status and related risktaking behaviors of a diverse sample of older adolescents enrolled in community college the results make a significant contribution to our understanding of the behaviors and cognitions associated with risky sexual behavior among community college students by building upon a relatively sparse body of literature findings reveal community college students may be at a high risk for experiencing poor sexual health outcomes and that there may be important risk pathways and intervention points to curb risky sexual behaviors in this underserved population the sexual health of community college students alarming differences in sexual assault victimization and intimate partner abuse exist between the students in this sample and students attending traditional fouryear colleges past 12month experience of rape or attempted penetration without consent was two to three times as high for both male and female students in the present sample compared to average college rates reported by american college health associationnational college health assessment 32 experience with being in a physically abusive relationship was also twice as high for both male and female students in the present sample 32 these differences may be attributable in part to the substantial differences in participants average age socioeconomic status or geographic location the achancha survey samples students primarily enrolled in fouryear institutions across the us representing a range of backgrounds whereas students in the present study were only recruited from community colleges in the southeast united states and many came from low income homes and identified as racial or ethnic minority students these demographic differences highlight the fact that community college students constitute a particularly highrisk group of late adolescents for a range of negative sexual health experiences and outcomes in the present study both male and female community college students experienced unwanted sexual advances attempted penetration and even rape at disturbingly high rates in addition to the serious emotional and physical repercussions associated with sexual assault victims may also be more likely to struggle academically and may eventually drop out of school after an incident 3940 thus the high prevalence of unwanted sexual experiences including rape may contribute to the high dropout rates reported by many community colleges 41 extrapolating from the findings in the present sample it may be important to directly address risky sexual behaviors and exposure to traumatic sexual experiences on community college campuses to improve both health and educational outcomes resources should be dedicated to preventing assault and abusive relationships among community college students and to providing survivors with adequate recovery supports while previous research has focused primarily on heterosexual female victims at residential fouryear institutions information is lacking in the community college setting about victimization especially among male students given the high proportion of male students who reported unwanted sexual experiences including rape in the present sample additional research is urgent and essential to better understand the patterns of perpetration and victimization in the community college setting the majority of students in this sample were living with a parent guardian or other family member which suggests that campus dormitories may not be the only place where assault and abusive relationships are a problem it is possible that older adolescents attending community colleges are at equal or elevated risk for assault andor abuse compared to those who are attending fouryear colleges or universities 42 differences may also be attributable to the lack of education about healthy relationships and a lack of supportive resources on campus for students attending community college although additional research is required in this area and no definitive conclusions can be made at the present time this study found that many students reported engaging in risky sexual behaviors such as anal sex about onefourth of female students in the sample reported having engaged in anal sex while these estimates are comparable to national estimates 4344 and anal sex among college populations seems to be on the rise 4445 many female students reported that their penetrative partner had not used protection this is a particular health concern given that anal sex increases the risk for acquiring certain stis including syphilis and chlamydia anal sex is also the single riskiest sexual behavior for transmitting hiv especially for the receptive partner 46 future research should examine these emerging patterns in sexual activity among college students more closely education around safe anal sex is important for students of all sexual identities with particular emphasis on the benefits of condom use some research suggests there could be a link between unprotected anal sex and coercion such that experiences of anal sex may often be unwanted among atrisk heterosexual female adolescents 47 future research should consider assessing how coercion sexual pressure or lack of communication shape the prevalence of anal sex and the use of protection during anal sex in this population the findings in this study related to stis also revealed a potentially urgent need for screening and preventative education among community college students very few participants reported they had received the hpv vaccine or had ever been tested for an sti according to 2013 data from the national college health assessmentii nearly 75 of females and 50 of male students aged 18to21yearsold have received the hpv vaccine 48 compared to less than half of females and only a third of males in this sample the american academy of pediatrics estimate that nearly 1 in 4 adolescent females aged 14to 19yearsold have had an sti 49 while only about 4 of students in this sample reported ever having an sti they also reported low rates of sti testing it is possible that the findings on sti rates in this study are underestimated given that many students are unaware of their sti status among sexually active males in the current sample only a third reported ever being tested for an sti in their lifetime compared to 38 of male community college students in california who reported being tested for hiv in the past year 11 the california study only included sexually active heterosexual community college students and these higher rates of recent testing may be due in part to variations in student demographics and geographic location for example california implemented the health services association california community colleges which works specifically to improve the health of community college students statewide and could have bolstered recent testing rates factors associated with future risky sexual behaviors as expected gender differences were found in intentions to engage in risky sexual behaviors male students in the sample were more likely to report higher intentions for sexual acts which may include multiple partners casual sex or intoxicated sex similarly endorsement of traditional gender role norms was associated with future risky sexual behaviors researchers have argued that internalized gender norms may lead men to pursue the masculine ideal of sexual adventurer while women may feel pressure pursue the stereotyped notion of feminine passivity 22 this could contribute to pressure for men to have more casual relationships while women may feel more pressure to acquiesce on important sexual decisions 22 gender norms reinforce imbalanced power dynamics between heterosexual partners but they also may discourage healthy communication between sexual partners one of the stereotypes of masculinity is to be unemotional and terse 50 men are acculturated even as children to avoid uncomfortable or emotional conversations 51 and aspiring to the stereotype of taciturn masculinity may leave male students more hesitant andor less equipped to talk to their partners about stis pregnancy prevention and even the emotional consequences of engaging in sexual intercourse some research indicates that endorsing traditional gender norms among men may be highly correlated with aggression antisocial behavior and low emotional awareness but also with earlier sexual initiation and less condom use 52 based on these preliminary findings interventions could be developed to help older adolescents deconstruct the social messages about gender expectations they receive through media and other cultural avenues popular media are inundated with images that convey gender norm expectations 53 and providing youth with media literacy education is one promising approach to disrupt acceptance and adherence to rigid gender role norms 54 another factor that was significantly associated with higher intentions for engaging in risky sexual behaviors was past sexual experience past behavior tends to be a strong predictor of future behavior and results suggest this may hold true for the present sample according to other research adolescents who become sexually active at earlier ages often have a greater number of sexual partners and more frequent intercourse compared to their peers 55 thus increasing their risk for poor sexual health outcomes sexual education and support for adolescents should begin early in order to delay initiation of sexual activity additional education and resources may still be relevant to equip students who are already sexually active with the skills they need to engage in sex while minimizing risk or to consider refraining from additional sexual encounters not surprisingly lower intention to communicate with a sexual partner about important sexual health topics was significantly associated with higher intentions to engage in future risky sexual behaviors during risky sexual encounters the need for communication about sexual health is of paramount importance however in the current study community college students who were engaging in more risky sexual behaviors were less likely to communicate with their partner about contraception sti history sexual history or pregnancy prevention educators should be positioned to teach and model communication skills by for example providing students with scripts that they could use for practicing sexual health communication the development and mastery of these skills through role play and group discussion could ultimately build stronger intentions to discuss sexual health open dialogue between potential sexual partners may also have the added benefit of reducing sexual assaults as the negotiation of consent is made more intentional and explicit although additional study in this area is needed several factors in these analyses were not associated with intentions for future risky sexual behaviors the findings revealed that students in the sample who were more likely to engage in risky sexual behaviors were similarly knowledgeable compared to their peers about sexual health risks andor medical outcomes as other research has suggested simply teaching factbased information about the consequences of risky sexual behavior may not be enough to deter future risk behaviors 56 57 58 similarly plans for sti testing and selfefficacy for condom use were not associated with students reported likelihood of future risky sexual behaviors rather than discount these arguably important factors related to sexual health future research could continue to examine how a combination of knowledge and skillsbased education which is inclusive and targeted to meet the needs of higherrisk groups can prevent sexual risk behaviors while other studies have suggested sexual behavior may differ by race ethnicity 5960 or sexual orientation 61 this study did not find that demographic characteristics were significantly associated with intentions to engage in risky sexual behavior additionally measures of ses such as pell grant eligibility or parental educational attainment were not significantly related to intentions around sexual risk behaviors for racial or sexual minority students and students from low ses backgrounds that do engage in risky sexual behavior they may have fewer resources or supports to manage negative socialemotional outcomes or to mitigate health problems resulting from these risky behaviors examining how demographic characteristics differ for observed sexual behavior and sexual health outcomes in this population is a direction for future research as most research has been conducted with majority heterosexual white samples attending fouryear institutions 6263 it is possible disparities in sexual health outcomes exist for this group even if demographic factors are not significantly associated with intentions to engage in risky sexual behavior this study adds to the literature supporting that the theory of reasoned action updated by the theory of planned behavior provides a useful but imperfect framework for understanding the cognitions related to risky sexual behaviors this theory connects attitudes norms and selfefficacy to intentions across sexual behaviors but does not address the role of affect in decision making this study found some of the tratpbinformed variables to be significantly associated with sexual risk behaviors but not all future research should also explore the role of affect and arousal in sexual decision making in order to test theory that does not assume purely rational choice limitations this study had several limitations data were only collected from community college students who owned a cell phone or tablet with internet access criteria met by approximately twothirds of all american community college students 64 the students without smartphone access may differ from students included in the study on important behaviors and outcomes students were approached and voluntarily chose to participate and therefore those who elected to participate may have been more informed about sexual health or more openminded to sexual health education efforts despite these limitations the sample was racially and economically diverse and was drawn from a group of community college students which constitutes an understudied underserved and highrisk population while students were sampled from multiple schools in both urban and rural areas this study only surveyed participants from a single state in addition the outcome measure may underestimate the true proportion of students actually engaging in risky sexual behavior the outcome measure was captured using an additive risk index that asked participants how much they felt it was likely they would engage in a number of risky sexual behaviors within the next six months according to some studies people may be more willing to engage in these behaviors or act irrationally in the moment but have lower explicit intentions to engage in these behaviors in the abstract 65 future research might examine willingness to engage in risky sexual behaviors under a range of interpersonal and contextual conditions in addition to assessing behavioral intentions furthermore this study uses intentions as a proxy for actual behavior the data were also selfreported and therefore may represent a social desirability bias for sensitive topics such as sexual activity intentions to engage in risky behaviors and sti disclosure methodologically the study utilized a crosssectional design and a causal relationship between the independent and dependent variables could not be evaluated other cognitive predictors of intentions could not be included in the adjusted model because they were very highly correlated with each other for example the investigators were interested in understanding the relationship between rape myth acceptance and intentions to engage in risky sexual behavior rape myth acceptance however was both highly correlated with gender and with gender norm acceptance so this variable could not be included in the adjusted regression models furthermore the small size of the sample prevented the inclusion of mediators and moderators in the analysis gender likely operates on sexual intentions through a number of cognitions but it was not possible to parse out these relationships in the present study future research should use larger sample sizes when possible to better understand the mediation and moderation pathways in sexual risktaking behaviors conclusions while research and resources around sexual health are typically focused on students attending fouryear colleges we cannot continue to ignore the other half of undergraduates in the united states who attend twoyear community colleges even when older adolescents are not living in a residential dormitory at a fouryear institution they are still at riskperhaps even at higher riskfor experiencing poor sexual health outcomes notably these community college students may be not only engaging in risky sex equally if not more than other college students but they also have access to fewer sexual health resources furthermore the national dialogue on sexual assault has largely excluded mention of community college students 63 yet there is growing evidence that they are in great need of education and support regarding their sexual health this study has identified a number of topics that could be addressed in educational programming for students first community college students may benefit from help finding appropriate and practical ways to have conversations with a sexual partner around stis and pregnancy prevention educational programs could also focus on reducing the negative impact of gender role stereotypes and promoting more equitable relationships 66 sharing knowledge about heathy relationships building skills around soliciting consent to engage in sexual behaviors and helping students stand up to prevent abusive or coercive relationships should be central tenets of any sexual health programming this is especially important given the alarmingly high prevalence of recent experiences with sexual assault rape and abusive relationships in this study sample at the policy level it may be important to partner with local health departments to provide sexual health resources on community college campuses such as sti testing hpv vaccinations condoms and referrals to health services such efforts are poised to substantially improve the health status of community college students bivariate and multivariate linear regression

objective this study examines the prevalence and risk factors associated with risky sexual behaviors in community college students participants a diverse sample of 1819yearold community college students n 264 results community college students in this sample disproportionately experienced sexual assault and were unlikely to test for stis higher intentions to engage in risky sexual behaviors were associated with gender and sexual experience but also with having lower intentions to communicate with a sexual partner about pregnancy and stis and having higher gender norm endorsementolder adolescents attending community colleges may be at high risk for poor sexual health outcomes and appropriate theorybased education should be tailored to meet the needs of these underserved students

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vietnamese had lower use of electronic print and interpersonal sources for ca ssb but more research is needed to disentangle potential effects of ethnicity and education this study brings to light striking potential differences between ca ssb of older lep vietnamese compared to whites african americans knowledge of ssb patterns among linguistically isolated communities is essential for efficient dissemination of cancer information to these atrisk communities for adults age 50 and older information about cancer holds particular relevance because of the agerelated increase in risk patients and other community members acquire cancer information through a variety of channels and these channels can impact the manner in which cancer information is conceptualized and used methods of knowledge acquisition can be categorized into two distinct categories information scanning and information seeking niederdeppe and colleagues describe information scanning as an umbrella term encompassing information acquired through customary exposure to knowledge sources information encountered incidentally or information acquired through browsing news and other sources insomuch as the information can be recalled with minimal prompt they classify information seeking as purposeful endeavors to acquire specific information in a manner transcending customary exposure to knowledge sources these two definitions of information scanning and seeking are adopted as the operational definitions implemented in this paper in addition information seeking and scanning behavior can be described further with regard to its breadth depth and relevance to decisionmaking the concept of ssb is clinically important because recent evidence from national data suggests a correlation between ssb and cancer screening behavior multiple factors influence to what extent health information is being accessed by individuals and population subgroups several studies have alluded to the influence that cultural background exhibits on health information seeking at least for latinos and african americans one contributing factor is the language barrier that members of some immigrant populations face in the midst of predominately english information sources beyond language however cultural incongruities between immigrant populations and the american health system can also impact the extent to which immigrant groups access health information for example some cultures have a strong narrative based communication tradition often relying heavily on storytelling for the purpose of education rather than entertainment in such cultures the process of sharing and seeking health information may differ from that which is customary in mainstream america asian americans unlike the majority american culture may also place greater emphasis on filial piety as well as collectivism conformity and humility patients from these minority backgrounds often feel that their doctors do not understand their values and have lower satisfaction in their medical care consequently such patients may be less likely to seek information from healthcare providers a study analyzing the disparities between asian americans and white americans in the health information national trends survey reported that asian americans had lower awareness of institutionalized information sources such as the american cancer society and national institutes of health and perceived their cancer risk to be low in comparison to the responses of their white counterparts additional investigations have suggested that ethnicity can play a determinate role in the selection of the medium through which cancer information is attained several reports indicate that asian americans are more likely to acquire healthrelated information from interpersonal sources as compared to white americans who are more inclined to use print literature or the internet vietnamese americans are among the fastest growing yet most linguistically isolated populations of asian americans in 2000 vietnamese americans were the fourth largest asian american population in the united states comprising almost 11 of asian americans within this large population over 60 speak english less than very well a 2006 study reported that vietnamese american men are more than twice as likely to use vietnamese newspapers or magazines than english ones as sources of health information but this study was not focused on older adults nor did it address cancer information in particular in addition like other immigrant groups linguistically isolated vietnamese americans may operate within social political or religious subcommunities that maintain ideologies that are largely inconsistent with most american health care practices for example such communities could hold negative views about seeking medical care in the absence of symptoms this paper describes a study comparing information seeking and scanning behaviors for breast prostate and colon cancers between older vietnamese americans and the general american population these cancers are among the most common malignancies in both populations the main aim was to investigate whether ethnicity is a factor in the extent and impact of cancer information acquisition for vietnamese americans we hypothesized that compared to whites and african americans vietnamese americans would access fewer cancer information sources be less likely to report information seeking and be more likely to use interpersonal sources as compared to electronic or print sources furthers we hypothesized that individuals who reported more ssb would also report more cancer screening methods this study is an extension of work published by niederdeppe and colleagues in brief data were collected using inperson semistructured interviews with respondents age 5070 the initial sample of white and african american participants from the general population described in the paper by niederdeppe et al was supplemented with additional interviews of vietnamese american immigrants conducted during the same time frame based upon prior experience with this hardtoreach minority community we chose to recruit participants for this segment of the study through communitybased organizations serving vietnamese american communities rather than using purchased lists of households members of marginalized communities are often reluctant to participate in activities unless they are introduced by trusted sources such as cbos this approach has been used by others for similar work vietnamese american participants were recruited from the same geographical boundaries used for the general population sample data were collected through semistructured interviews using the same questions described in the prior work by niederdeppe et al however all questions were translated into vietnamese and backtranslated to assure lexical equivalence all interviews for the vietnamese american subsample were conducted in vietnamese additional questions specific to the vietnamese immigrant population were asked at the conclusion of the interview further details regarding collection of interview data for the vietnamese subsample are published elsewhere in total 104 interviews of white african american and vietnamese american participants were included in this study men were asked about information seeking and scanning behaviors related to colon cancer and prostate cancer and women were asked about colon cancer and breast cancer ssb questions were designed to elicit responses that would distinguish between ssb related to primary prevention and ssb related to screening thus each participant was asked questions using a fourmodule framework breast or prostate cancer primary prevention breast or prostate cancer screening colon cancer primary prevention and colon cancer screening all interviews were digitally recorded and transcribed verbatim vietnamese interviews were then translated into english by a research support company with extensive experience in multilingual project support the textual data were managed using n6 qualitative research software the data were coded by multiple reviewers for presence of cancerrelated information seeking or scanning behavior breadth of ssb depth of ssb and relevance to decisionmaking for cancer primary prevention and screening breadth was measured as the number of sources used to seek or scan for a decision depth was dichotomized into those who recalled at least general ideas from a source of cancer information and those who did not recall any substantive information from that source this depth of recall was based purely on selfreport because there was no reliable and feasible way to assess whether each piece of recalled information was actually being remembered in an accurate fashion even scientific accuracy of the information described by participants could not be used for this purpose because there was no guarantee that the original information to which participants had been exposed was scientifically correct from the start consequently depth of recall was based on more contextual features relevance to decisionmaking was determined based upon responses to the question did that information lead you to do anything afterwards which was asked whenever participants reported exposure to any cancerrelated information further details regarding the data collection procedure semistructured interview protocol coding procedures and ssb measures are available in previously published papers the coded data were analyzed using spss 120 for windows all of the study materials were approved by the institutional review board of a major university prior to their implementation we tested for disparities in overall ssb by comparing racialethnic subgroups using the wilcoxin ranksum test stratified by information source similar analyses were carried out for depth of recall and information relevance to decision making comparisons were also made with regard to the number of sources used for each type of decision in addition analyses also evaluated racialethnic differences in information seeking recall and relevance to decisionmaking in order to test the hypothesis that vietnamese americans place more significance on interpersonal sources than on other sources of information the sources were divided into 3 categories for some analyses electronic media print media and interpersonal sources once again the reported use of these grouped sources was analyzed by race ethnicity finally we performed logistic regression to identify predictors of 4 outcomes active seeking of cancer information use of electronic media for cancer information use of print media and use of interpersonal sources as independent variables we included raceethnicity education gender age and marital status categorical variables were converted to dummy variables for regression analyses due to differences in education between vietnamese and nonvietnamese samples we included an interaction term to test for effect modification in the results we will present a comparison of the three racialethnic groups in a variety of ways first we will focus on breadth of ssb next we will present racialethnic comparisons for the presence of active information seeking depth of information recall and decisionmaking relevance stratified by cancer type finally we will break this down to the specific types of cancer information sources and their relationship with information seeking depth of recall and relevance to decisionmaking in addition we will describe selfreported cancer screening in relation to cancerspecific ssb for the full sample and for the vietnamese american subsample alone results a total of 104 respondents were interviewed for this study characteristics of the sample are shown in table 1 the mean age for vietnamese americans was slightly older that that of whites and african americans but the difference was not statistically significant differences in gender and marital status were also not statistically significant however discrepancy in educational status between vietnamese americans and the other two groups was statistically significant vietnamese americans were considerably less likely to report engaging in cancer information seeking and scanning behaviors than whites and african americans table 2 focuses on the breadth of ssb and compares the racialethnic groups by behavior type gender and cancer type these results demonstrate that vietnamese americans uniformly used fewer sources for both primary prevention and screening ssb across all three cancers all three racial ethnic groups used substantially more sources for screening than they did for primary prevention women generally accessed more sources than men in all groups table 3 focuses on the remaining dimensions of ssb presence of active information seeking depth of recall and relevance to decisionmaking vietnamese americans reported less seeking lower recall and less information relevance to decisionmaking for colon cancer and to a lesser extent for breast and prostate cancer comparable results were found for information scanning and ssb for all three cancers combining all three cancers close to 100 of whites and african americans could recall general ideas from ssb and found ssb to be relevant to their decision making in contrast less than twothirds of vietnamese americans demonstrated recall of cancer information similarly less than twothirds of vietnamese americans cited ssb as relevant to their decision making process figure 1 illustrates the types of sources used for ssb over 90 of whites and african americans reported use of electronic media print literature and interpersonal sources for ssb meanwhile interpersonal sources were the only category accessed by more than half of vietnamese americans as shown in table 4 vietnamese americans also reported less ssb lower recall and less relevance to decision making for each of the individual sources under investigation doctors were the most used source of information for respondents of all racesethnicities followed closely by friends and family although the percentage of vietnamese americans who accessed these sources was about half that of their counterparts television newspaper and pamphlet use was reported by the majority of whites and african americans but these sources played a substantially diminished role in the ssb of vietnamese americans 5 failed to identify significant differences between vietnamese and nonvietnamese participants for overall active seeking of cancer information nor for the use of electronic sources and print sources for any cancer ssb however in the case of interpersonal sources for any cancer ssb being vietnamese and high schooleducated was an independently significant predictor for not using interpersonal sources meanwhile being nonhighschooleducated was not associated with any significant differences from the reference category the regression analyses were limited by the fact that there were few nonvietnamese participants with less than high school education regression analyses also suggested that older age predicts increased use of electronic media print media and interpersonal sources for cancer ssb female gender also appears to predict increased use of print media and interpersonal sources for cancer ssb logistic regression table history of mammography was reported by 981 of nonvietnamese and 90 of vietnamese participants selfreported screening was lower for prostate cancer and colon cancer table 6 shows the percent of participants who reported screening for breast prostate and colon cancer stratified by whether any ssb was reported for each cancer a positive association was found for ssb and cancer screening this was statistically significant for the full sample but not for the vietnamese american subsample alone in order to explore the question of whether the collectivist vietnamese culture played a role in explaining why their ssb appeared to be lower we reviewed the portions of the vietnamese interview transcripts pertaining to interpersonal communication whereas reports of active information seeking were minimal participants spoke at length about being exposed to cancer information when it happened to emerge in casual conversations with friends and family members if someone in a persons social circle had cancer or had cancer screening for example the topic became more relevant to the respondents discussion this is the first report comparing cancer information seeking and scanning behaviors of vietnamese americans to those of the larger american population while it is important to recognize that increased ssb does not necessarily equate with increased knowledge these results raise important questions with regard to the role of vietnamese ethnicity and cancer ssb moreover inasmuch as our data suggest that increased ssb is potentially associated with increased cancer screening the fact that vietnamese study participants reported lower cancer ssb could have negative downstream effects on screening behavior as hypothesized vietnamese american participants reported accessing fewer cancer information sources and lower cancer information seeking compared to whiteafrican american participants in this sample of older adults age 5070 years while vietnamese americans did not report using interpersonal sources at higher rates than nonvietnamese vietnamese participants did report using interpersonal sources more often than electronic and print sources many of our findings are consistent with existing literature in a study of online health information seeking lorence and colleagues found that more whites reported health information seeking than asian americans the results also correlated with a 2003 investigation that found that nonjapanese asians and pacific islanders selected physicians and people in general as among the top three most frequently accessed sources of health information these prior studies did not specify collection of data in asian languages therefore leaving unanswered questions about whether nonenglish speaking asian americans would report similar behaviors our results also showed that doctors and friendsfamily were considered the most relevant sources for decision making which is in agreement with published vietnamese american focus group data suggesting that doctors and patients are considered the most credible sources of health information unlike our study however this prior work did not include comparisons between vietnamese americans and the general population in hints 2003 637 of adults report use of internet for health information with highest use among those who were other race in contrast our findings show lower healthrelated internet use among asians as compared to whites and blacks in interpreting these differences it is important to note that hints is a survey of adults from a broad range of ages whereas our study focused on much older adults even more importantly the asians included hints were not entirely representative of the entire asian american population due to its poor representation of asians with higher age lower income and lower education thus our sample captured an important segment of the asian american population that was excluded from hints the hints data also suggested that older americans are less likely to use the internet as compared to younger adults while our study showed a statistically significant increase in use of electronic media with increased age however the actual size of this effect was quite minimal and therefore may not be important from a practical standpoint our results regarding the use of interpersonal sources to the near exclusion of other sources of information differed from a 2006 study reporting that englishproficient asian americans were more likely than whites to chose printed publications as a source of cancer information whether our results are particular to the vietnamese american community should be investigated further moreover studies should explore whether people from more collectivist cultures might find cancer information from interpersonal sources to be more salient than do people from individualist cultures comparison of seeking depth of recall and decision relevance for each cancer type revealed statistically significant differences for colon cancer but not for breast or prostate cancer this might be related to power limitations since both male and female participants provided data regarding colon cancer while analyses surrounding breast and prostate cancer relied on half as many participants due to the gender specific nature of these cancers while the median number of sources used for ssb about cancer screening was significantly different between raceethnicities for every cancer type it was not significant for every cancer with regard to primary prevention this could be due to low statistical power or floor effects this study was limited by the difference in sample selection process between vietnamese american and the other participants however it was necessary to use community based organizations for recruitment due to the limited accessibility of linguisticallyand culturallyisolated vietnamese americans another potential limitation is that a disparity existed between the level of educational attainment of the vietnamese american participants as compared to african american and white participants this educational discrepancy however is consistent with reports that vietnamese americans have the worst educational attainment of all major asian subpopulations in the united states we attempted to address potential effects of education through addition of an interaction term for ethnicity and education but this was limited by the low number of nonvietnamese participants who failed to complete high school consequently the regression findings with respect to ethnicity and educational attainment should be considered purely exploratory future work should attempt to disentangle the potential effects of education and raceethnicity in this regard the question of acculturation should also be addressed since the sample size of the present study did not allow the effects of acculturation on ssb within the vietnamese sample published research has demonstrated an effect of acculturation on television use among hispanics and internet use among east asians so it is likely that this would hold true for vietnamese americans finally it is important to note that given the sample size age range and limited geographical area these findings might not be generalizable to every community and it would be helpful to have followup studies in other cities as well as with other age groups the results of this study suggest that older vietnamese americans access cancer information at disparate rates when compared with their white and african american counterparts across all sources multivariate analyses are less clearcut and further study is warranted if it is true that older vietnamese americans tend to prefer cancer information from interpersonal sources over print and electronic sources a potentially effective strategy might be to work with communitybased social networks to encourage discussions about health with reliable sources such as physicians public health workers and peer health educators efforts to encourage cancer information seeking in this population might also be worthwhile but safeguards would be needed to ensure that information seekers have appropriate health literacy to discriminate between accurate and inaccurate sources further research on the topic of health communication behaviors and preferences in linguistically isolated ethnic minorities is crucial in our increasingly multicultural society use of electronic print and interpersonal sources for cancer information seeking and scanning by raceethnicity sources used depth of recall and relevance to decision making

information seeking and scanning refers to active pursuit of information and passive exposure respectively cancer ca is the leading cause of mortality for asian americans yet little is known about their ca information seekingscanning behaviors ssb we aimed to evaluate ca ssb among older limited english proficient lep vietnamese immigrants compared to whites african americans 104 semistructured interviews about breastprostatecolon ca ssb age 5070 were conducted in english and vietnamese transcribed and coded for frequency of source use activepassive nature depth of recall and relevance to decisions higher ssb was associated with ca screening in contrast to nonvietnamese ssb for vietnamese was low median of ca screening sources was 2 vs 89 for nonvietnamese they also had less seeking lower recall and less decisionmaking relevance for information on colon ca and all ca combined overall

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the global covid19 pandemic brought about unprecedented disruptions to our daily lives governments imposed restrictions and limitations on social life leading to considerable reductions of facetoface social contact for people the world over involuntary curbs to social interactions conflict with humans basic need for belonging psychologically and neurobiologically humans interpret involuntary social isolation as social ostracism sensitivity to ostracism peaks in adolescence a period of life when young people are biologically and socially primed to spend time with their peers this developmental imperative for social reorientation has been disrupted by the pandemic adolescents may therefore be particularly vulnerable to adverse effects of these social restrictions on their mental wellbeing adolescent mental health during the covid19 pandemic studies investigating the impact of the pandemic on adolescent mental health have provided evidence for its detrimental impact on this age group crosssectional research comparing data collected during the pandemic to prepandemic statistics consistently demonstrates elevated levels of mental health problems in adolescents during the pandemic longitudinal studies show similar yet somewhat more equivocal trends while most longitudinal studies reported an increase in symptoms of depression and anxiety during the pandemic a set of white papers showed no changes in internalizing symptoms or an increase in depression only but not anxiety barendse et al a noteworthy study due to its large and international sample of 918yearolds found that the most negative mental health impacts were reported by adolescents under lockdown restrictions together these findings suggest that young people indeed suffer however it remains unclear whether they are at greater risk of pandemicrelated mental health problems than adults the current study therefore examined agerelated variance in mental health problems in a sample ranging from early adolescence to old age mental health problems were assessed at three time points at threemonth intervals during the first year of the pandemic from may 2020 to april 2021 to explore whether more stringent government restrictions to social interactions had a more detrimental impact on mental health during the pandemic participants were included from the usa uk and australia three countries that varied in their government restriction stringency indices importantly the current study went beyond describing the extent of the mental health impact of covid19 and related government restrictions by exploring why young people may be at greater risk for experiencing mental health problems during the pandemic why are adolescents at greater risk for mental health problems during the covid19 pandemic adolescence is a period of risk for the development of mental health disorders with 75 of all cases emerging by age 24 compared to adults adolescents experience more negative affect and more variable mood states in their everyday lives such emotional reactivity occurs in the context of cognitive development and social change marked by increased time spent with peers and heightened sensitivity to peer acceptance and influence adolescents particularly girls are also hypersensitive to social rejection with research showing that social rejection has a greater negative impact on adolescents mood compared to adults given the social sensitivity that characterizes adolescents as well as their increased need for peer interaction the physical distancing measures that have been imposed as a result of the covid19 pandemic may have had a greater negative impact on adolescents compared to adults social connectedness reduced social connectedness due to physical distancing measures during the pandemic may be one determinant of poor mental health in young people this hypothesis has been supported by findings from longitudinal studies for example greater increases in depression and anxiety symptoms as well as suicidal ideation were observed in adolescents who felt socially disconnected whereas 715yearolds who reported more social connectedness were less likely to develop mental health problems after experiencing pandemicrelated stressors in line with these findings a systematic review on the impact of social isolation and loneliness on adolescent mental health in the context of covid19 indicated that they were likely to significantly increase the risk of mental health problems in young people indeed loneliness has long been considered a significant public health issue it can impair executive functioning sleep as well as physical and mental wellbeing and lead to an increased risk of morbidity and mortality high levels of loneliness in the context of covid19 have been reported particularly in young people social support in turn was found to be protective against increased loneliness heightened loneliness and decreased social support during the pandemic were associated with elevated depression anxiety and suicidal ideation however the adverse effects of increased loneliness due to periods of enforced physical distancing may have been mitigated by engaging in social interactions with peers and family via online platforms the potential of online social interactions for mitigating loneliness and social disconnection however remains underresearched in a rare prospective study participants who felt more lonely during the pandemic were less likely to seek out online interactions in another study youth who reported lower levels of digital socialization had heightened internalizing symptoms during the pandemic controlling for prepandemic symptoms while in a crosssectional study of young people there was no association between the frequency of virtual social interactions and wellbeing loneliness social support and social interactions may therefore interact to contribute to changes in mental health throughout the pandemic this may be particularly the case for adolescents who show greater reliance on their peers for social connectedness reduced social connectedness we propose is most detrimental to individuals with high levels of sensitivity to social rejection social rejection sensitivity refers to the tendency to anxiously expect readily perceive and overreact to social rejection social rejection sensitivity has been linked both crosssectionally and prospectively to depressive and anxiety symptoms there is also evidence that rejection sensitivity is associated with an aversion to aloneness molinari et al suggested that individuals high in social rejection sensitivity in particular tend to see aloneness as something negative an indicator of being rejected indeed as noted at the outset as a species involuntary social isolation signals rejection from the group and is associated with risk to biological fitness thus reduced facetoface social contact may be particularly detrimental for rejection sensitive individuals as they are likely to perceive this reduced social contact as an indication of rejection the current study the current study longitudinally examined the relationship between social connectedness social rejection sensitivity and mental health from early adolescence to old age during the covid19 pandemic data were drawn from the covid19 risks across the lifespan study an online longitudinal study comprising predominately female participants designed to investigate how the changes brought about by the covid19 pandemic have affected peoples wellbeing and social connectedness baseline data were collected between may 5 th 2020 and september 30 th 2020 participants who completed at least 65 of the baseline survey were recontacted via email to complete two followup measures critically the design of the study allowed for a naturalistic manipulation of the level of physical distancing and enforced social isolation experienced by participants specifically by recruiting individuals from australia the uk and usa we were able to investigate the extent to which differing levels of government restrictions in response to covid19 including physical distancing influenced our results our preregistered predictions were that greater government restrictions in response to covid19 including those on social interactions and lower age would lead to greater increases in mental health symptoms across time additionally we predicted that these associations between mental health problems and age and country would be partially accounted for by social connectedness and that this relationship would be moderated by social rejection sensitivity that is heightened mental health problems in individuals residing in a country with greater covid19 restrictions and those of younger age would vary as a function of decreased social connectedness this association in turn was predicted to be strongest in individuals who experience higher levels of social rejection sensitivity method measures only those measures included in the analyses for the current study are reported below all selfreport measures had acceptable internal consistency which is reported below revells total omega which has been shown to overcome the limitations and stringent assumptions of cronbachs alpha was used to measure internal consistency while there is no universal guide to evaluate ωt scores of 050 and higher are considered to reflect acceptable internal consistency demographics participants provided a series of demographic measures including age selfidentified gender selfidentified ethnicity and highest educational attainment which was used as a proxy for socioeconomic status for participants under the age of 18 the average of their parentsguardians highest educational attainment was used as a proxy for socioeconomic status government restrictions in response to covid19 participants country of residence was used as a proxy for government restrictions in response to covid19 the stringency index is a composite measure of nine indices computed by the oxford coronavirus government response tracker project a database of international policy responses to covid19 from the study commencement date until the date of study preregistration the average stringency index in the uk was 733 in the usa 685 and in australia 636 note ses socioeconomic status for participants over the age of 18 years ses was operationalised as their highest educational attainment for participants under the age of 18 years ses was operationalised as the average of their parents highest educational attainment high university middle high school or professionalvocational training low primary school 1 the mental health measures were included in the latter half of the online questionnaire thus a substantial proportion of participants did not reach this point in the questionnaire and were consequently excluded from analyses given the approximately equidistant values between countries in the current study stringency was rank ordered from 3 to 1 in addition participants were asked the extent to which they were adhering to physical distancing measures in place in their community rated on a scale from 1 to 6 which was controlled for in analyses covid19 risk binary response items assessing whether participants or anyone in their home had been quarantined due to possibly having covid19 whether participants had been hospitalized due to covid19 or whether participants knew anyone personally who had been diagnosed with hospitalized due to or passed from covid19 were included in the study these items were combined into a covid19risk variable to control for the potential impact of covid19related risk on mental health social rejection sensitivity the online and offline social sensitivity scale was used as a measure of social rejection sensitivity the 18item scale assesses social rejection sensitivity in both offand online contexts respondents indicated the extent to which they endorse such items as i always expect criticism on a 4point likert scale ranging from 0 to 3 the scale has shown good internal consistency and good convergent validity with symptoms of emotional disorders the o 2 s 3 demonstrated good internal consistency in the current study this scale was only administered at t1 social connectedness social connectedness throughout the covid19 pandemic was assessed using several metrics including the ucla loneliness scale and a series of bespoke items indexing change in facetoface and technologyassisted interactions as well as social support from family and friends during the pandemic the ucla loneliness scale is a 20item selfreport measure designed to assess subjective feelings of loneliness as well as feelings of social isolation participants responded to such items as i am unhappy doing so many things alone on a 4point likert scale ranging from 0 to 3 the scale has demonstrated good psychometric properties including high internal consistency and testretest reliability the scale had good internal consistency in the current sample this scale was administered at all timepoints the bespoke items asked participants to indicate on a visual analogue scale ranging from 0 100 the extent to which the following had changed since the start of the pandemic or since the previous time point facetoface contact with friends playing video games messaging or texting on a mobile phone tablet or computer visiting social media sites video callingchatting voice callingchatting getting support from friends getting support from family members the interaction items showed acceptable internal consistency at each time point 2 mental health problems symptoms of depression were assessed with the 8item patient health questionnaire the measure facetoface video game messaging social media video calling and voice calling interactions change in each type of interaction since the start of the pandemic or since the previous time point measured on a visual analogue scale ranging from 1 5 social support from friends and family change in social support from friends and family since the start of the pandemic or since the previous time point measured on a visual analogue scale ranging from 1 5 has been shown to be a reliable index of depression and has demonstrated excellent psychometric properties participants indicated the extent to which they had been bothered by such things as little interest or pleasure in doing things in the previous two weeks on a 4point likert scale ranging from 0 to 3 the measure demonstrated good internal consistency in the current study additionally the 7item general anxiety disorder scale was administered to assess symptoms of anxiety participants were asked to indicate how often they had been bothered by such problems as feeling nervous anxious or on edge over the previous two weeks on a 4point likert scale ranging from 0 to 3 the gad7 has evidenced good reliability and validity and good internal reliability was observed in the current study finally mental wellbeing was assessed with the 7item short warwickedinburgh mental wellbeing scale which has shown good psychometric properties from adolescence to older age this measure was reverse scored for analyses good internal reliability was observed in the current study mental health measures were administered at all timepoints procedure this study was approved by the university of new south wales human research ethics committee prior to taking part in the study all participants were required to provide online informed consent participants under the age of 18 years required parental consent before they were able to access the study parents completed an online consent form and were then provided with a link and study access code for their child participants then completed the online survey on qualtrics and cognitive task on the cognitron platform participants first provided demographic information after which they completed the social interaction and social support items followed by the ucla loneliness scale the phq8 the gad7 the wemwbs and finally the o 2 s 3 data analysis prior to hypothesis testing preliminary analyses were conducted to model mental health problems and social connectedness as latent variables and to subsequently test for measurement invariance of these latent variables our preregistered method was to fit one mental health latent variable with items from the phq8 gad7 and wemwbs loading on to a single unidimensional factor and a separate social connectedness latent variable with items from the ucla loneliness scale and the social interactions and social support items loading on to a unidimensional factor while a single mental health latent variable fit the data a unidimensional social connectedness latent variable did not fit the data due to low correlations between items from different measures as such the loneliness items interactions items and social support items were modelled as separate latent variables all latent variables demonstrated measurement variance across countries predicted values for each latent variable were extracted and used in all analyses trajectories of change in mental health problems were analysed using latent growth curve modelling to address our first hypothesis that individuals residing in countries with greater government stringency in response to covid19 would show greater increases in mental health problems across time a multigroup latent growth curve model was specified with country of residence specified as the categorical grouping factor the intercept was coded as 1 for each timepoint and slope was coded linearly as 0 1 2 the intercept of the model thus represents mental health problems at t1 whereas the slope represents linear change across time mental health problems were modelled as a latent factor score with depression symptoms anxiety symptoms and wellbeing items loaded onto individual factors followed by the three factors loaded onto an overall mental health general factor higher scores on this latent factor score thus indicate greater mental health problems to determine whether individuals from countries with differing levels of government stringency demonstrated distinct mental health trajectories a model comparison approach was adopted first three separate multigroup models were fit one which allowed the intercept to differ across countries one which allowed the slope to differ across countries and one which constrained both the intercept and slope to be the same across countries the fit statistics for the freed intercept and slope models were then compared to the fit statistics of the constrained model significant differences between countries in baseline mental health and rate of change in mental health across time were indicated by a significant chisquared test between the freed intercept and constrained model and between the freed slope and constrained model respectively in all models gender ethnicity covid19 risk at t1 and adherence to physical distancing at t1 were controlled for3 the impact of these covariates was constrained across countries as were the error variances for the intercept slope and mental health latent factors at each time point to address our second hypothesis that younger individuals would show greater increases in mental health problems across time age was added as a continuous timeinvariant covariate to the bestfitting multigroup model predicting both intercept and slope in this model predictors of intercepts address interindividual differences in mental health problems at t1 whereas predictors of slope address intraindividual differences in changes in mental health problems across time to address our third hypothesis that the impact of age and country on mental health problems would be mediated by social connectedness a series of longitudinal mediation models were specified including age or country as the predictor and mental health problems at t3 as the outcome variable change in loneliness interactions and social support from t1 to t3 was included as the mediator thus a total of six mediation models were specified all models controlled for mental health problems at t1 as well as gender ethnicity t1 covid19 risk and t1 adherence to physical distancing a moderated mediation was planned as a second step including social rejection sensitivity as the moderator if any significant indirect effects were observed this deviates from our preregistered method of analysis which had proposed a moderated mediation latent growth curve model however due to the added number of latent factors the moderated mediation model became too complex to interpret and longitudinal mediation was instead adopted all analyses were conducted in r studio version 410 using the lavaan package and the interactions package using robust full information maximum likelihood estimation to account for missing data model fit was assessed using standard criteria with acceptable fit indicated by comparative fit index and tuckerlewis index values ≥ 90 and root mean square error of approximation and standardized root mean square residual values ≤08 figures were made using ggplot2 and ggpubr an r script containing the analyses code can be found on the open science framework results hypothesis 1 the impact of government restrictions on mental health problems across one year of the pandemic to address h1 that changes in mental health problems across the pandemic would vary as a function of country of residence a multigroup latent growth curve model was specified controlling for gender ethnicity covid19 risk and physical distancing adherence covid19 risk measured as a composite score of exposure hospitalisation and covid19 mortality in next of kin and friends was included in the model to control for impact of existential threat on mental health problems adherence to physical distancing restrictions was included as a covariate in the model to model interindividual variance in adherence across countries a model with linear slope in which the intercept of mental health problems was allowed to vary across countries fit significantly better than a model in which the intercept was constrained across countries indicating that participants residing in the uk the usa and australia showed differing levels of mental health problems across the first months of the pandemic specifically individuals in the uk showed the greatest level of mental health problems followed by individuals in the usa and australia a model in which the slope of mental health problems was allowed to vary across countries did not fit significantly better than a model in which the slope was constrained across countries thus participants residing in countries with differing levels of government restrictions in response to covid19 did not show differential changes in mental health problems across one year of the pandemic indeed the slope was not significant indicating that there was no significant change in mental health problems across the course of the study the freed intercept model demonstrated an excellent fit to the data hypothesis 2 the impact of age on mental health problems across one year of the pandemic to address h2 that changes in mental health problems across the pandemic would vary as a function of age age was added as a timeinvariant predictor to the bestfitting multigroup model the model provided an excellent fit to the data again the slope was not significant indicating that overall mental health problems remained stable from t1 to t3 age significantly predicted the intercept but not the slope that is younger individuals experienced significantly greater mental health problems in the early stages of the pandemic compared to older individuals with these inequalities in mental health problems remaining constant across one year of the pandemic at t1 adolescents reported mental health symptoms that place them in the moderate clinical range for both depression and generalized anxiety disorder based on prepandemic norms adults scored in the mild clinical range hypothesis 3 the relationship between country age social connectedness and mental health problems next a series of longitudinal mediation models were specified to address h3 that the impact of age and country on mental health problems would be partially accounted for by social connectedness and would vary as a function of social rejection sensitivity we first investigated the mediating effect of the social connectedness variables on the impact of age and country on mental health problems country social connectedness and mental health neither changes in loneliness frequency of social interactions nor social support mediated the relationship between country and mental health problems at t3 while controlling for mental health problems at t1 gender ethnicity t1 covid19 risk and t1 adherence to physical distancing measures in each model there was no significant direct effect of country on mental health problems at t3 there was also no effect of country on changes in loneliness frequency of social interactions or social support similarly there was no effect of changes in frequency of social interactions on mental health problems at t3 suggesting that whether or not individuals increased or decreased their facetoface and virtual interactions with others during the pandemic did not significantly impact on mental health problems at t3 however there was a significant moderate effect of changes in loneliness and a significant small effect of changes in social support on mental health problems at t3 thus greater increases in loneliness across time predicted greater mental health problems after one year of the pandemic whereas greater increases in social support predicted fewer mental health problems after one year of the pandemic age social connectedness and mental health when examining the indirect effect of social connectedness on the relationship between age and mental health problems at t3 no significant indirect effects were observed however in each model there was a significant small effect of age on mental health problems at t3 thus younger age predicted significantly greater mental health problems at t3 over and above mental health problems at t1 gender ethnicity and covid19 risk and physical distancing adherence at t1 age also significantly predicted changes in the frequency of social interactions but not change in loneliness or social support as in the country models there was a moderate effect of changes in loneliness a small effect of social support and a nonsignificant effect of frequency of social interactions on mental health problems at t3 anxiety symptoms measured with the 7item general anxiety disorder scale and mental wellbeing measured with the 7item warwick edinburgh mental wellbeing scale time 1 was between may 5 th 2020 and september 30 th 2020 time 2 was between august 5 th 2020 and january 29 th 2021 and time 3 was between november 5 th 2020 and april 9 th 2021 the countries varied in governmentimposed covid19 restrictions with the uk reporting the highest level of government restrictions the usa intermediate levels and australia reporting the lowest levels of government restrictions during the study period the moderating role of social rejection sensitivity across the mediation models younger age significantly predicted more mental health problems as did changes in loneliness and social support we next investigated the moderating role of social rejection sensitivity on each of these relationships the effects of loneliness and social support were investigated in separate linear models and a model comparison approach was adopted to determine the significance of interaction effects this differs from our preregistered method of analysis which had proposed a moderated mediation latent growth curve model however given that we did not find significant mediation effects of social connectedness on the association between age and country with mental health we instead investigated the impact of the moderator through linear models first a main effects model in which age loneliness and social rejection sensitivity predicted mental health at t3 controlling for mental health problems covid19 risk and physical distancing adherence at t1 country gender and ethnicity was compared to a model which additionally included an interaction between social rejection sensitivity and loneliness the addition of the interaction term significantly improved model fit the main effects model was also compared to a model which included an interaction between social rejection sensitivity and age again the addition of the interaction term significantly improved model fit a final linear model was specified including the aforementioned main effects and covariates as well as the two interaction terms in this model age loneliness change and social rejection sensitivity significantly predicted mental health problems at t3 these main effects were qualified by a significant interaction between social rejection sensitivity and age and between social rejection sensitivity and loneliness simple slopes analyses revealed that age had a significant effect on mental health problems when social rejection sensitivity was average or high but not when social rejection sensitivity was low the effect of change in loneliness on mental health problems was significant across all levels of social rejection sensitivity however this effect was greater the higher the social rejection sensitivity to investigate the effect of change in social support on mental health problems a main effects model including age social support and social rejection sensitivity as predictors and controlling for mental health problems covid19 risk and physical distancing adherence at t1 country gender and ethnicity was compared to a model which included an interaction between social rejection sensitivity and social support the inclusion of the interaction term did not significantly improve model fit when comparing the main effects model to a model which included an interaction between social rejection sensitivity and age the inclusion of the interaction term significantly improved model fit thus the linear model including the aforementioned main effects covariates and an interaction between social rejection sensitivity and age was retained in this model change in social support and social rejection sensitivity significantly predicted mental health problems at t3 over and above the effect of mental health problems covid risk and physical distancing adherence at t1 country gender and ethnicity the main effect of age was not significant however again there was a significant interaction between social rejection sensitivity and age discussion brain social and cognitive development is driven by our experiences during adolescence peer interactions note mh1 mental health problems at t1 mh2 mental health problems at t2 mh3 mental health problems at t3 mental health problems were modelled as a latent factor score comprising depression symptoms measured with the 8item patient health questionnaire anxiety symptoms measured with the 7item general anxiety disorder scale and mental wellbeing measured with the 7item warwick edinburgh mental wellbeing scale covid19 risk was a composite score comprising a series of bespoke binary items indexing whether participants had been quarantined or hospitalized due to covid19 or whether they knew anyone who had been diagnosed with hospitalised or passed away from covid19 physical distancing adherence was a bespoke item indexing the extent to which participants were complying with the physical distancing measures in place in their community measured on a scale from 1 to 6 due to large amounts of missing data on the covid19 risk and physical distancing adherence variables at t2 and t3 only t1 values of these variables were controlled for are central to experiencedependent neural and socioemotional development this developmental process was disrupted by the advent and ongoing nature of the covid19 pandemic the detrimental impact of enforced social isolation on young peoples mental health needs to be dissected here we examined the impact of known social risk and protective factors prospectively as predicted levels of governmentenforced covid19 restrictions and age were associated with mental health problems specifically individuals living in a country with higher government stringency reported worse mental health problems throughout the study period even when controlling for covid19risk and adherence to physical distancing regulations younger age was also associated with more mental health problems at each of the three assessment timepoints increased loneliness across the three study assessment points was associated with more mental health problems at the final time point whereas increased social support was associated with fewer mental health problems changes in frequency of facetoface and online social interactions were not significantly related to mental health outcomes in the current study the impact of age and loneliness on mental health problems was moderated by social rejection sensitivity younger age in individuals with moderate to high levels of social rejection sensitivity was associated with more mental health problems at the final assessment but not in those with low levels of social rejection sensitivity increases in loneliness across the study period were associated with the worst mental health outcomes in those individuals highest in social rejection sensitivity together these findings demonstrate that social risk and protective factors are key determinants of mental health during the covid19 pandemic especially in young people since the emergence of covid19 and subsequent enforcement of strict and extended lockdown measures to combat the virus mental health researchers have warned of an impending mental health crisis what has now been termed a shadow pandemic here we found that individuals residing in countries with greater government stringency in response to the pandemic including those in the uk and usa demonstrated consistently higher mental health problems across the first year of the pandemic moreover in the current study we observed substantially heightened depression and anxiety symptoms at all timepoints when compared to prepandemic norms indeed average depression scores in adults at the first assessment time point were in the mild clinical range and in the upper moderate clinical range for adolescents even when considering selfselection to participate in a psychological study on the impact of covid19 on mental wellbeing these are exceptionally high average levels of depression while the observational nature of the current study and lack of prepandemic data and direct measurement of physical distancing precludes causal interpretations together these findings do suggest that the covid19 pandemic and ensuing lockdowns have had a significant impact on mental health a pattern observed in a growing number of longitudinal studies including prepandemic data especially in young people in line with our preregistered predictions and a growing body of research mental health problems specifically increased symptoms of depression and generalized anxiety and reduced wellbeing were associated with increases in loneliness throughout the pandemic mental health problems were modelled as a latent factor score comprising depression symptoms measured with the 8item patient health questionnaire anxiety symptoms measured with the 7item general anxiety disorder scale and mental wellbeing measured with the 7item warwick edinburgh mental wellbeing scale social rejection sensitivity was measured with the 18item online and offline social sensitivity scale loneliness was measured with the 20item ucla loneliness scale and modelled as a latent factor score while we did not investigate the reciprocal nature of this relationship recent research conducted during the pandemic found a bidirectional relationship between loneliness and depressive symptoms indeed a recent qualitative synthesis of studies of the experience of loneliness among young people with depression highlighted the mutually reinforcing nature of this relationship the authors argue that the manner in which depressed individuals engage in certain behaviours such as withdrawing and not confiding in others about their symptoms can lead to feelings of loneliness an awareness of these feelings of loneliness can in turn perpetuate depressed individuals negative mood states thus mental health interventions that target loneliness may lead to improvements in symptoms and vice versa our results extend this general finding by investigating and providing support for the hypothesis that loneliness is particularly detrimental to those characterized by heightened levels of social rejection sensitivity that is increased loneliness impacted those participants most who were most sensitive to social rejection this fits with theoretical models of social rejection sensitivity which argue that heightened social rejection sensitivity is marked by excessive distress in response to social uncertainty and ambiguity ever changing social distancing directions including school closures and working from home orders have introduced high levels of uncertainty regarding the potential for social contact indeed isolation is likely to be interpreted by rejection sensitive individuals as a rejection signal as a group adolescents feel social rejection particularly keenly the current results showed that the association between mental health across one year of the pandemic and age was moderated by social rejection sensitivity that is young people high on social rejection sensitivity showed the highest levels of mental health problems after one year of the pandemic whereas in those with low levels of social rejection sensitivity age was not significantly related to mental health outcomes again this supports the proposal that the detrimental impact of social isolation and uncertainty experienced within the context of the current pandemic was greatest in those high in social rejection sensitivity the current findings thus suggest that social rejection sensitivity may be an important intervention target especially for young people while little research has investigated the malleability of social rejection sensitivity there is preliminary evidence that negative interpretation bias mediates the association between the tendency to anxiously anticipate rejection and depressive symptoms importantly metaanalytic evidence suggests that negative interpretation bias can be modified via targeted training thus interventions that challenge negative interpretations about social rejection may help decrease mental health symptoms in those sensitive to rejection in the absence of opportunities for facetoface contact during periods of physical distancing many individuals may have turned to virtual means such as social media in order to maintain a sense of social connectedness however whether such virtual platforms help or hinder mental health has been a source of much debate in the literature our findings suggest that whether or not individuals increased or decreased their facetoface and virtual interactions with others during the pandemic did not significantly impact on their mental health this is consistent with some recent findings showing that the duration or quantity of interactions with others on virtual platforms is not associated with mental health outcomes during the pandemic instead it may be the quality of virtual interactions that is important more generally increased social support was associated with fewer mental health problems in the current study which is in line with previous findings during the pandemic these findings need to be interpreted within the context of the studys limitations first we collected a convenience nonprobability sample and consequently our findings may not be representative of the population indeed with the rapid proliferation of research on the mental health impact of covid19 concerns have arisen as to whether nonprobability samples provide an accurate representation of a population response consequently our findings may be biased as a consequence of the people who are likely to take part in such surveys for example those who are more engaged and interested in the topic and also have access to the internet moreover most participants identified as female white and were of midhigh socioeconomic status limiting the generalizability of these findings female gender in particular could be argued to be associated with greater social rejection sensitivity however metaanalytic evidence provides no support for gender differences in the association between social rejection sensitivity and mental health similarly a previous study in a sample of participants with high ethnic socioeconomic and gender diversity showed that the impact of these demographic variables did not moderate the impact of social rejection sensitivity on mental health while we included selfidentified gender and ethnicity as covariates in all analyses the lack of representativeness of our sample limits the conclusions we can draw about the impact of these demographic variables on mental health trajectories another limitation of the current study was that we did not include a direct measure of physical distancing at each timepoint instead the stringency index was used as an overall indicator of countrylevel physical distancing future studies should model timevariant social restrictions combined with more finely differentiated geolocalization to support the current findings additionally our study did not include prepandemic data which limits the conclusions that can be drawn from our findings regarding the direct impact of the pandemic and associated restrictions indeed while we found that participants residing in countries with greater government stringency reported higher mental health problems at baseline trajectories of change in mental health problems across the course of the study did not vary as a function of government stringency thus it is possible that the differences in the intercepts captured preexisting differences in mental health problems between countries moreover while we found that younger age was associated with more mental health problems at all timepoints in the absence of prepandemic data we cannot conclude that these discrepancies are a consequence of the pandemic and do not merely reflect agerelated differences in mental health finally the moderating impact of social rejection sensitivity on the relationship between age and loneliness with mental health problems may not be specific to the pandemic and instead may reflect the fact that those participants with higher social rejection sensitivity already had higher mental health problems during the covid19 pandemic our findings converge with recent studies highlighting young people as being particularly vulnerable to increased mental health problems during the pandemic and additionally highlight loneliness and social support as key risk and protective factors respectively social rejection sensitivity was also found to predict increased mental health difficulties particularly in younger people and those who experienced a greater increase in loneliness however despite its role as a key risk factor for adolescentonset internalizing symptoms there is currently a surprising lack of interventions directly targeting social rejection sensitivity thus our findings highlight the need to design novel easytodisseminate interventions targeting social rejection sensitivity reducing social rejection sensitivity especially in young people may lead to improved resilience in the context of perceived and actual isolation and loneliness supplementary material to view supplementary material for this article please visit author contributions ss and sm conceived of the study sm and as collected the data ao sm and ss analysed the data sm and ss drafted the manuscript and all authors provided critical revisions all authors contributed to the funding application and approved the final version of the manuscript for submission app1184136 and jacobs foundation the funding sources did not have any involvement in the study design in the collection analysis and interpretation of data in the writing of the report and in the decision to submit the article for publication conflicts of interest none

belonging is a basic human need with social isolation signaling a threat to biological fitness sensitivity to ostracism varies across individuals and the lifespan peaking in adolescence governmentimposed restrictions upon social interactions during covid19 may therefore be particularly detrimental to young people and those most sensitive to ostracism participants n 2367 8995 female 11100 years from three countries with differing levels of government restrictions australia uk and usa were surveyed thrice at threemonth intervals may 2020 april 2021 young people and those living under the tightest government restrictions reported the worst mental health with these inequalities in mental health remaining constant throughout the study period further dissection of these results revealed that young people high on social rejection sensitivity reported the most mental health problems at the final assessment these findings help account for the greater impact of enforced social isolation on young peoples mental health and open novel avenues for intervention

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introduction it is commonly assumed that older adults are not a high risk group for hiv infection 1 however the prevalence and incidence of hiv among people age 50 and over are increasing 2 there is a growing body of literature pertaining to hivaids among older adults in the united states and europe but less is known about hivaids among older adults in the developing world in this introduction we examine hivaids among older adults a review of the literature was conducted for two main purposes 1 to identify some of the factors that contribute to the growing hivaids prevalence and incidence rates among older adults in general drawing heavily from the us and european literature and 2 to summarize the limited literature focused on hivaids in china with particular attention to what is known about older chinese plhwa hiv among older adults in the united states and europe in the united states approximately onequarter of persons living with hivaids in 2005 were 50 years of age and older 3 by 2012 onethird of those living with hiv in north america western and central europe were aged 50 or older 4 worldwide there are an estimated 36 million older adults living with hiv 4 the increasing prevalence of hivaids among older adults is largely due to the effectiveness and availability of highly active antiretroviral treatment that has allowed for a address correspondence to this author at the factorinwentash faculty of social work department of family and community medicine university of toronto 246 bloor st w toronto on m5s 1a1 canada tel 416 9783269 fax 416 9787072 email significant increase in the lifespan of individuals living with hivaids 5 6 7 and a lowering in the incidence of hiv among younger adults in europe and north america 4 in addition there are also persistently high rates of new hiv infections in older adults 7 of particular concern a recent british study indicates that older adults seek initial treatment later in the disease progression and have almost a threefold risk of mortality in comparison to younger adults with hiv 8 a number of explanations both social and physiological have been posited for the increase in incidence in hiv infection among older adults research indicates that older persons have limited knowledge about hivaids 9 yet they are less likely to receive prevention education 10 11 12 older adults are engaging in more sexual activities than previous cohorts of older adults due to the availability of erectiledysfunction drugs like sildenafil and tadalafil 1314 however condom use to prevent the transmission of hiv has been found to be low among older adults 1415 older women are thought to be especially vulnerable to hiv infections due to specific physical changes associated with normal aging processes which increase susceptibility to the virus 12 research also indicates that intravenous drug use has become a pathway to new hiv infection among older adults 16 many older adults do not believe they are at high risk for contracting hiv 13 or aids 14 especially older women 17 symptoms of hivaids are often mistaken for agerelated disorders 816 consequently often older adults are not screened for hivaids by their health care practitioners 815 and do not seek out hiv testing 818 these factors may lead to an hiv diagnosis at a later stage in the disease course 819 among older adults with hivaids there have been particularly large increases in the number of women minorities and lower income groups infected 20 older adults with hivaids confront unique health challenges 21 the combined effect of hivaids and the aging process may cause older adults to process and respond to antiretroviral drugs differently than younger adults with hivaids and may increase vulnerability to opportunistic infections and other diseases 2 research indicates that many older adults living with hivaids receive inadequate social support 722 partially due to the double stigma of aging and living with hivaids 7 unfortunately the research on hivaids among chinese americans in general and older chinese americans in particular is extremely limited this lack of research may be due to the relative rarity of hivaids among this population in 2009 only 11 of all persons living with hiv infection in the united states were of asian origin 23 hivaids in china the estimated prevalence of hivaids in the population is 006 24 in 2009 the number of hiv positive chinese citizens and new infections was approximately 740000 and 48000 respectively 24 research shows that among adults in china intravenous drug use and heterosexual sexual contact are the primary modes of infection 25 female sex workers men who have sex with men and intravenous drug users are particularly vulnerable to infection 25 condom use has been found to be infrequent among some high risk populations such as clients of female sex workers 26 research shows that among adults in china there is limited participation in voluntary hiv testing particularly among adult women 27 due to the increasing availability of highly active antiretroviral treatment in china many younger and middle aged adults with hivaids live to age 50 and beyond hivaids has shifted from an acute illness to a chronic disease among older adults in china the reported cases of hivaids have substantially increased in 2006 older adults aged 5064 represented 61 of all reported cases of hivaids however by 2009 this percentage almost doubled to 106 24 despite the large increase in the number of older adults with hivaids in china researchers have not paid enough attention to this population the limited research on older people living with hivaids has shown that plasma and blood donations during the 1990s were the main mode of infection of older adults in china the commercial blood and plasma donations were disproportionately situated in rural areas and the vast majority of older adults in china live in rural areas despite the significance of this group little is known about the demographic profile and needs of rural elders with hivaids to enhance outreach education and screening efforts it is important to develop an understanding of the characteristics of older adults with hivaids in rural china using data from a large study conducted by the first and last author in three provinces in 20062007 we develop a profile of older populations infected with hivaids in rural china we also compared this group with younger hivpositive rural chinese methods survey the data presented in this study are from a crosssectional survey conducted in rural areas of three provinces from november 2006 to february 2007 these provinces have a high prevalence of hivaids people living with hivaids who were over 18 years of age were eligible to participate in the study only one plwha was interviewed per household the institutional review board of beijing normal university approved the study protocol more details about the survey are available elsewhere 2829 the local civil affairs department provides ongoing financial assistance to plwha individuals receiving civil affairs funding for plwha were notified through the local civil affairs department about the possibility of volunteering for this study plwha who were interested in being interviewed were provided with information on how to directly contact study staff each interview took approximately one and a half hours and the respondents received rmb 20 in compensation for their participation once plwha who were interested in being interviewed had contacted a member of the survey team they were asked their preference for the time and location of the interview the interviews were conducted in the location selected by the participant before starting the survey informed consent was obtained from plwha who agreed to take part in the survey each participant was assured of confidentiality participants were aware they could withdraw from the survey at any time without penalty there were 185 plwha aged 50 or older and 681 younger plwha statistical analysis and measures this study examined differences between younger and older respondents with hivaids chisquare analysis was used to compare the two groups with respect to demographic sociodemographic and health characteristics social support and perception of the impact of hiv on their lives the analysis was conducted using spss 115 software the following demographic variables were investigated regional distribution gender education level marital status the year of diagnosis and the extent to which social support was received from each of the following sources parents children and siblings plwha were also categorized by clinical stage of the disease haart is available free of charge to all individuals with fullblown aids variables investigated included whether the plwha could take care of themselves independently employment status whether medical care was received since diagnosis respondents perception that medical care has eased family burden and that there has been a big impact of hivaids on household income and on childrens schooling results of the 866 respondents one fifth were 50 years of age and over most of the older plwha were female illiterate married and at the clinical stage of hiv there were regional differences by age group the majority of older respondents came from henan only 7 came from yunnan province in contrast the population aged 49 and younger were evenly divided between the 3 provinces women make up a disproportionately high percentage of the older plwha among respondents aged 49 and younger each gender was equally represented there was a significant difference between older and younger populations with hivaids with regard to their education and marital status older plwha had completed fewer years of school and were more likely to be widowed over half of older plwha were illiterate and onequarter were widowed for both younger and older people the main reason for being widowed was that their spouse had died of aids older plwha are less likely to be in the labor force than younger people with hivaids over half of older adults infected with hivaids were diagnosed approximately four years before the 20062007 interview in comparison to onethird of the younger plwha older adults with hivaids were more likely to be in the aids stage of the disease and were more likely than younger people to need the assistance of others in their personal care there were significant differences in receiving medical treatment and medical care between the two groups the older population was more likely to receive treatment and to think the effects of medical care were more helpful as was shown in table 2 younger plwha were more likely than older adults to receive support from their parents and siblings in contrast the main source of social support for the older population infected with hivaids was their children compared to younger plwha a higher percentage of the older population reported that they had few close friends andor were isolated from their family and were living alone older plwha were also less likely than younger plwha to participate in any activities provided by organizations including religious organizations nongovernmental organizations or selfhelp groups older respondents were less likely than younger plwha to report that the impact of hivaids on their household income or their childrens schooling was huge discussion the majority of older plwha in our sample were infected through commercial blood and plasma donations over half of older respondents were female and were illiterate our analysis shows that older plwha were more likely than younger plwha to live alone to be isolated and to have few sources of social support in this study most of the older plwha were living in henan and anhui provinces while the percentage of older plwha in yunnan province accounted for less than 10 the uneven distribution of older adults with hivaids among the different provinces is closely related to the main transmission modes in each province generally older people had few chances to receive formal education especially in rural china fourfifth of the older plwha had less than a middle school education and half were illiterate our analysis shows that younger people were less likely to receive treatment and less likely to report that medical care greatly decreased the burden on their family research has shown older plwha to be more compliant with medication regimes than younger plwha 30 this may reflect the fact that older adults were more likely to have fullblown aids than younger plwha the impact of hivaids on household income and childrens schooling among the younger age group was more pronounced than it was among older adults younger respondents are more likely to be in their prime earning years and to be the main wage earner in the household plwha under the age of 50 are also more likely to have underage dependents than older respondents thus it is not surprising that the younger plwha were more likely to report a huge economic impact in comparison to the older cohort all respondents both young and old relied heavily on family members for social support this result is similar to previous findings that older adults living with hivaids rely heavily on friends and family members to provide social support 7 younger people mainly received social support from their parents and siblings while older people were more likely to be supported by their children this pattern of intergenerational exchange is common in developing countries without wellestablished pension and social security programs this tradition is deeply rooted in chinas culture of filial piety 31 hivaids undermines the traditional context of caregiving the younger people who would normally be the main financial supporters of households have become the most affected group of plwha thus the normal direction of intergenerational exchange support has been reversed facing the devastating impact of hivaids on younger people many older parents have had to provide shelter and financial support to their adult children with hivaids and to their grandchildren older people with hivaids had fewer friends than younger plwha in addition older people were more likely to live alone than younger people due to the death of spouses and other loved ones compared to younger people with hivaids older people were less likely to be involved in organized activities previous north american research suggests older persons with hivaids are more likely than younger plwha to become socially isolated themselves 32 we found congruent with existing us research that older people with hivaids tend to receive less social support than younger plwha 33 they are also more likely to be isolated by aids stigma and ageism 7 thus the older population with hivaids is more likely than younger plwha to become socially withdrawn due to a lack of strong networks furthermore older adults may also need to cope with life transitions such as the death of a spouse 34 threefifth of older people with hivaids in this study were female disproportionate representation of older women among older persons with hivaids also has been noted elsewhere 12 the sex ratio in our chinese sample may result from two reasons greater female longevity and gender differences in rural to urban migration women are more likely to survive into old age than men among those aged 65 and older in china the ratio of men to women is 092 35 however the ratio of older men to women in our study represents an even larger discrepancy it has been common for the past two decades for rural men to move to the cities in search of work leaving the women and children in their rural communities for example a 1999 study of anhui and sichuan province showed that rural to urban migrants were 67 male 36 the commercial blood contamination occurred in the rural villages which were probably disproportionately female implications for practice and policy this study has important implications for social service program development and policy initiatives targeted at older plwha in rural china the fact that one in five of those with hivaids in this study was aged 50 and over underlines the magnitude of this hidden population 37 and the importance of hivaids health professionals and service providers tailoring programs to serve this cohort furthermore with women representing the majority of older plwha in our analysis there is a need to incorporate a gender sensitive strategy into rural aids programs and policy initiatives the variation across provinces in the age distribution of plwha highlights the inappropriateness of a centralized one size fits all program to provide services to the hiv infected population and to prevent further spread of hiv prevention in several of our survey locations nongovernmental organizations had organized selfhelp groups with the aim of providing aids information and assistance for people infected with hivaids our findings suggest that 85 of older adults do not participate in any activities established by organizations such as religious groups ngo andor selfhelp group making it clear that this strategy for disseminating information is not sufficient for the older age cohort with such low rates of group attendance among older adults other oneonone forms of service provision and information sharing are preferable low literacy levels may contribute to a lack of knowledge on how to prevent hivaids infection flyers using clear visual images rather than words to explain ways to minimize the spread of hiv have been created for illiterate populations in other countries 38 it is possible that flyers could be developed to inform illiterate rural individuals in china whether or not they are infected with hivaids the combination of low literacy rates and extensive use of highly active antiretroviral treatment in both younger and older rural chinese plwha presents important issues for health care providers the most effective use of haart requires greater than 95 compliance with the complex and demanding drug regime traditional wordbased patient information leaflets are of minimal assistance to individuals with low literacy chinese health care providers may benefit from the lessons learned from south african programs using creative pictographbased leaflets to better inform illiterate patients of negative side effects of haart such as vomiting peripheral neuropathy fever and dizziness and to clarify information on medication usage 39 within china similar pictograms refined through cultural consultation could potentially help to improve comprehension and improve recall of important medication related information among haart patients social isolation was a substantial problem for many of the older plwha health professionals and social service workers should routinely ask clients with hivaids about the social support they are receiving and isolation issues they face 40 for isolated seniors referrals to resources in the community including recreational older adult groups as well as hivspecific older adult support groups may be helpful home based health care organizations can provide assistance through volunteers or trained health professionals when individual providers consistently serve particular patients the opportunity arises for the development of an ongoing supportive relationship which can decrease the social isolation of the client conclusions this study is a preliminary exploration of the difference between older and younger populations with hivaids in rural china in order to develop a complete picture of older plwha in china more research attention should be directed to urban older adults infected with hivaids due to the large differences between urban and rural areas in china in addition gender perspectives should also be incorporated into future research due to the disproportionately high percentage of older women who have hivaids there are several limitations in this study first in order to get enough respondents our sample was drawn from villages with high hivaids prevalence rates second there was a selfselection effect such that only those interested in participating contacted the interviewers in order to be in the study therefore results of this study cannot be generalized thirdly our data set is crosssectional longitudinal data could profile how peoples situations changes as they age with hivaids and if the needs of those who acquire hivaids later in life differ from their peers who acquire the disease at a younger age despite these limitations our study provides the largest investigation to date examining the characteristics of older plwha in rural china the findings lay a solid foundation for designing effective programs to service the older plwha population in rural china conflict of interest the authors confirm that this article content has no conflict of interest

although the number of older people living with hivaids plwha has increased substantially few studies have focused on older plwha in developing countries based on a sample of 866 rural plwha in henan anhui and yunnan provinces in china this study compares the characteristics of plwha aged 50 or older n185 with younger plwha n681 most of the older plwha were female n112 illiterate married and at the clinical stage of hiv over 90 of older people with hivaids lived in henan and anhui provinces the severe epidemic in henan and anhui provinces was caused by commercial blood and plasma donation older plwha were less educated received less social support and were more likely to live alone than younger plwha the results underline the importance of developing programs and policy initiatives targeted at older people infected with hivaids the policy and program recommendations include using a gender sensitive strategy designing specific aids education and prevention programs suitable for lowliteracy older adults and social support interventions for older plwha

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introduction in several countries currently we are facing a new type of mass sociogenic illness that in contrast to all previously reported episodes of msi is spread solely via social media and hence is not locally restricted so far no such social mediainduced episodes have been described although by 2012 it was speculated that msi may not require in any case direct visual or verbal contact among the persons affected 1 for this new type of msi we therefore suggest the more specific term mass social mediainduced illness hereby we want to raise awareness of its global occurrence since only correct diagnosis enables appropriate treatment and termination of symptoms 2 moreover msi outbreaks are socially and economically costly 3 independently of how they spread this study has been approved by the local ethics committee at hanover medical school 15042020 no 8995bos2020 prerequisites enabling current outbreak of social mediainduced illness msmi recently in several countries including germany uk 4 usa 5 denmark france and canada an increasing number of videos were released on social media platforms such as youtube tiktok and instagram showing people who claim to be suffering from tourette syndromea childhood onset chronic combined motor and vocal tic disorderwhile in fact most individuals had functional symptoms only resembling tourette syndrome on 21 february 2019only shortly before the first patient with msmi presented in our clinic in may 2019the german youtube channel gewitter im kopf was launched by a 22yearold man called jan zimmermann judging from the videos he indeed suffers from a mild form of tourette syndrome on this youtube channel however he shows a countless number of movements vocalizations words phrases and bizarre behaviours that he claims are tics but are clearly functional in nature tourette experts can easily tell the difference 67 since the majority of supposed tics are complex and stereotyped and mimic those symptoms that laypeople typically associate with tourette syndrome coprolalia copropraxia and nonobscene socially inappropriate behaviours for most of the shown symptoms there are obviously strong situational contexts with exclamations of long sentences with insults swear words and obscenities that are in this form unknown in tourette syndrome furthermore the number of symptoms and in particular the number of different swear words and insults presented are countless and thus far beyond those of tics in tourette syndrome finally presented symptoms quickly change on an almost weekly basis in parallel to newly released videos while most popular symptoms are repeated several times soon after it was started the youtube channel gewitter im kopf was rapidly spread on social media and reached 1 million subscribers in 53 months making jan zimmermann the top youtube breakout creator in germany in 2019 he earned further attention from the youtube and internet community by participating in other popular youtube channels and tv shows through posts of these shows on youtube and reaction videos from the highestearning influencers in germany unge and montanablack and by receiving special tubeawards today jan zimmermann is the second most successful youtube creator in germany and enjoys enormous popularity among teenagers gewitter im kopf is subscribed to by 220 million people and 336 videos have been released that were viewed 315 826 001 times in total 8 meanwhile the channel is accompanied by a merchandising campaign and most popular exclamations are reproduced on products such as shirts and caps 9 finally a mobile app has been released including the most popular supposedly vocal tics 10 already on 4 june 2019 the two most relevant german advocacy groups tourette gesellschaft deutschland and interessenverband tic tourette syndrom distanced themselves from the youtube channel 11 and later on from the app 12 because of their obvious misrepresentations and disrespect to people with tourette syndrome affected teenagers of msmi present with functional tourettelike symptoms over the past 2 years a remarkably high number of young patients have been referred to our specialized tourette outpatient clinic presenting with symptoms closely resembling the ones jan zimmermann shows in his videos all these patients had been prediagnosed with tourette syndrome even partly as treatmentresistant tourette syndrome after having received pharmacotherapy with different drugs including antipsychotics remarkably in none of these cases neither the correct diagnosis of functional movement disorder had been made nor had the interrelation with and influence by social media been recognized although a detailed description of clinical characteristics is beyond the scope of this paper and is currently in preparation for publication elsewhere here we want to briefly summarize how in this group of patients diagnoses of tourettelike fmd were confirmed first all patients presented with nearly identical movements and vocalizations that not only resemble jan zimmermanns symptoms but are in part exactly the same such as shouting the german words pommes bombe heil hitler du bist ha ¨ßlich and fliegende haie as well as bizarre and complex behaviours such as throwing pens at school and dishes at home and crushing eggs in the kitchen even more similar to jan zimmermann words and phrases are pronounced with a changed voice at low pitch so that family members are able to differentiate normal conversation from the supposed vocal tics solely on the basis of the tone of voice second a substantial number of patients gave their supposed tourette syndrome a name just as jan zimmermann does who calls his symptoms gisela third patients often reported to be unable to perform unpleasant tasks because of their symptoms resulting in release from obligations at school and home while symptoms temporarily completely disappear while conducting favourite activities fourth in some patients a rapid and complete remission occurred after exclusion of the diagnosis of tourette syndrome although some patients did indeed suffer in addition from mild tourette syndrome for all newly emerged symptoms it could be clearly ruled out that they were tics for several reasons onset was abrupt instead of slow symptoms constantly deteriorated instead of typical waxing and waning of tics simple movements and noises were clearly in the background or completely absent although being the most common and typical symptoms in tourette syndrome movements were mainly complex and stereotyped and predominantly located in the arms and body instead of in the eyes and face overall the number of different movements noises and words was countless and far beyond the typical number of tics in tourette syndrome and premonitory feelings were reported with atypical location quality and duration compared to tics in tourette syndrome thus worsening of preexisting tourette syndrome for example due to the covid19 pandemic as suggested elsewhere 45 can be clearly ruled out in our patients msmi is initiated by virtual index cases in general an index case is necessary for the initiation of an msi outbreak 313 in the current msmi outbreak in germany jan zimmermann can be regarded as a virtual index case meanwhile more and more people with tourettelike fmdincluding some of our patientsappear on the german internet and tv thus spread via social media seems to induce secondary virtual index cases resulting in further spread without local restrictions because of the extremely high degree of recognition of these videos among young people we assume that spread is also possible simply by verbal communication interestingly at the same time in other countries similar channels launched on youtube and tiktok so these influencers may act as further virtual index cases 45 based on the already initiated exchange among international tourette experts it seems that patients identified in germany exhibit some differences compared to cases seen in other countries such as canada while it appears that age at onset is very similar in different countries with a preponderance of adolescents and young adults gender distribution seems to be different while half of our patients are male the group of davide martino and tamara pringsheim at the university of calgary in canada reports a female to male ratio of about 91 this difference might be related to the different gender of most influential virtual index cases in germany compared to canada while we were able to clearly identify the german speaking man jan zimmermann as a virtual index case in contrast in canada ticlike symptoms in young patients seem to be mainly triggered by the presentation of such behaviours by the englishspeaking 20yearold female evie meg or better known under her tiktok name thistrippyhippie justification of the concept of msmi in 2012 bartholomew et al 1 stated it is unclear if mpi could spread solely via social media among people with no other preexisting connection besides spread through personal sight and sound for the current msmi outbreak all criteria for classical msi are fulfilled meaning a constellation of symptoms suggestive of organic illness but without an identifiable cause that occurs between two or more people who share beliefs related to those symptoms 3 while our patients did not have direct personal contact with either jan zimmermann or among each other they made indirect contact with jan zimmermann in the form of strong identification patients reported admiring jan zimmermann for his open approach to the supposed tourette syndrome and for being successful despite his condition which causes strong emotions and hence further triggers contagion 14 thus the current outbreak of tourettelike symptoms can be regarded as a new variant of msi where social media serve as an extension of our eyes and ears 1 and replace the necessity of being in direct visual or verbal contact with others for spread besides general replacement of facetoface communication by use of social media tools 1 increased use of social media during covid19 related lockdown and quarantine might be a reinforcing factor 1516 we do not believe that our patients should be simply diagnosed as tourettelike fmd instead of being affected persons of an msmi outbreak since the first patients presented in our clinic only 3 months after launch of the youtube channel gewitter im kopf and all patients confirmed having watched these videos beforeor in some cases even duringmanifestation of similar or identical symptoms furthermore functional movements resembling tics have been described only rarely in a very limited number of case studies 17 18 19 20 21 22 accordingly functional ticlike movements have been classified as a relatively rare type of fmd that occurs in only about 5 23 and primarily affects adults 17 interestingly only recently an increase in fmd during the covid19 pandemic has been reported from a us movement disorder centre with tremor being the most common presentation 5 similar to our cases however one teenager developed functional tics after watching another teenager on tiktok apparently presenting with tourette syndrome tourettelike msmi episode represents a modern form of motor variant of msi msi is differentiated in two variants an anxiety variant presenting with unspecific symptoms such as abdominal pain headache dizziness fainting nausea and hyperventilation triggered by extreme sudden stress within a closeknit group and a motor variant with hysterical dancing convulsions laughing and pseudoseizures 24 while the anxiety variant was believed to represent the modern form of msi in western cultures that is typically triggered by environmental factors with odour as the most common and typical predictor 13 the motor variant seemed to be a more primitive form that mainly occurred in the middle ages 3 for example in 1374 and again in 1518 bizarre outbreaks with exaggerated movements known as dancing plagues have been reported 25 interestingly outbreaks of the motor variant developed in relation to natural disasters and required a prolonged buildup of psychological tension associated with a mood of catastrophe and desperation in social groups united by some strong religious belief 2526 furthermore longterm anxiety uncertainty and longstanding stress perceived not only as threatening but also as inescapable seem to play a major role 327 in malaysia in 1978 a motor variant msi outbreak among college students was associated with higher education and intense competition for prestige and leadership 28 while similar outbreaks in east africa in 196263 were closely related to rapid socioeconomic changes 29 most of these outbreaks took weeks or months to subside 1 worth mentioning in leroy new york in 2012 a tourettes epidemic occurred in a high school affecting 19 adolescents with suddenonset ticlike behaviour 3031 speculations about the cause of this leroy outbreak as well as intensive media interest initially led to further increase before symptoms rapidly declined once the diagnosis of msi was established 3233 although schools are the most frequent settings for msi outbreaks 3 already at that time influence by social media had been suggested 1 and the treating neurologist david lichter commented this mimicry goes on with facebook or youtube exposure this is the modern way that symptomology could be spread 34 the 21st century motor variant of msi is triggered by ecoanxiety and the covid19 pandemic about half of generation z feels stressed or anxious with climate change being the top concern 35 ecoanxiety is associated not only with fear panic attacks feelings of anger guilt and helplessness but also uncontrollability unpredictability and uncertainty 36 the covid19 pandemic may cause additional increase in anxiety and restrictions because of the lockdowns may result in increased stress due to home schooling significant changes in families living together associated with increased rates of conflicts and domestic violence lack of communication with friends reduced or no contact to peer groups and boredom 1516 thus this current outbreak of msmi represents not only the modern form of msi motor variant but can also be viewed as the 21st century expression of a culturebound stress reaction 37 of our postmodern society emphasizing the uniqueness of individuals and valuing their alleged exceptionality 38 thus promoting attentionseeking behaviours 39 and aggravating the permanent identity crisis of modern man 40 it can be assumed this is triggered by ecoanxiety the covid19 pandemic and further challenges in postmodern society 35 based on recent reports 45 and personal communication with experts in several countries an enormous number of young people affected with tourettelike msmi can be assumed to have considerable impact on health care systems and society as a whole since spread via social media is no longer restricted to specific locations such as local communities or school environments fortunately first international efforts are already underway to expand our knowledge of this phenomenon such as an experts survey initiated by the european society for the study of tourette syndrome 41 and an informative website launched by canadian experts at the university of calgary 42 presumably different initiatives from different parties in different countries are needed to stop current spread of functional tourettelike behaviours this may include experts interviews in different languages in the media 43 44 45 46 education and training of physicians psychologists and students of clinical characteristics of tics and tourette syndrome compared to functional movement disorders information via tourette syndrome advocacy groups possibly foundation of new advocacy groups specifically for patients with functional tourettelike behaviours and finally clear concepts to differentiate one from the other competing interests

we report the first outbreak of a new type of mass sociogenic illness that in contrast to all previously reported episodes is spread solely via social media accordingly we suggest the more specific term mass social mediainduced illness in germany the current outbreak of mass social mediainduced illness is initiated by a virtual index case who is the second most successful youtube creator in germany and enjoys enormous popularity among young people affected teenagers present with similar or identical functional tourettelike behaviours which can be clearly differentiated from tics in tourette syndrome functional tourettelike symptoms can be regarded as the modern form of the wellknown motor variant of mass sociogenic illness moreover they can be viewed as the 21st century expression of a culturebound stress reaction of our postmodern society emphasizing the uniqueness of individuals and valuing their alleged exceptionality thus promoting attentionseeking behaviours and aggravating the permanent identity crisis of modern man we wish to raise awareness of the current global tourettelike mass social mediainduced illness outbreak a large number of young people across different countries are affected with considerable impact on health care systems and society as a whole since spread via social media is no longer restricted to specific locations such as local communities or school environments spread via social media is no longer restricted to specific locations such as schools or towns

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background dementia stigma is a key concern of dementia advocacy 1 stigma is defined as negative stereotyped beliefs feelings and behaviours 2 3 4 cultural stigma is societys shared negative beliefs prejudices and discriminatory structures 5 examples of dementia cultural stigma include public fear of dementia 67 therapeutic nihilism 8 and locked dementia care units 9 dementia stigma contributes to delayed helpseeking 67 a reluctance by health professionals to give a dementia diagnosis 10 and human rights violations of people with dementia 9 dementia stigma means that people with dementia frequently feel denied and ignored and experience discrimination in healthcare 1 perceived stigma by people with dementia is associated with depression anxiety and lower selfesteem personal control and activity participation 11 and with depression in care partners 12 culture is our learned system of shared ideas rules and meaning that influence how we act on and view the world 13 popular culture is the set of practices beliefs and materials that embody the shared meanings of a social system and includes news and social media books and television and linguistic conventions 14 popular culture reflects and influences attitudes and behaviour for example the metoo movement 15 in order to be able to intervene to decrease dementia stigma we need to understand cultural stigma related to dementia 5 current dementia awareness raising campaigns describe dementia biomedically or alternatively depict a highly positive image of living well with dementia these may have unintended consequences of exacerbating stigma through highlighting the neuropathological otherness of people with dementia or by insufficiently showing the difficulties experienced by people with dementia so that those who did not live well might feel they have failed 16 pescolido et al 17 suggest that the portrayal of dementia in the media influences and reflects cultural stigma stereotypes of dementia in the media are that people with dementia are old and severely impaired passive and have no quality of life 1819 when news and entertainment media reinforce negative stereotypes this perpetuates stigma 20 frame analysis is one method of describing cultural stigma a frame is a central organising idea or story line that provides meaning to an unfolding strip of events that impacts on how information is interpreted 22 frames may be suggested through slogans analogies pictures and connect the issue with deeper values 23 this paper approaches the description of cultural stigma through the lens of popular culture our aim is to systematically review and synthesise research on the depiction of dementia in popular culture focusing on the view of healthcare humanities and social sciences a qualitative systematic review of academic papers was chosen to bring together academic analysis across different types of media as analysis of original sources over the many media types was assessed to be too broad in scope methods scoping search an initial search of scopus was undertaken followed by an analysis of the title abstracts mesh and index terms of relevant articles this was used to inform our final search terms systematic search a search was conducted in december 2017 and updated in january 2019 databases searched were scopus pubmed psychinfo and embase title abstract and keyword searches were conducted restricting results to english language articles published between 1989 and 2018 this time period was chosen to capture the articles on the last two decades of media depictions because more recent media is more likely to impact on current perceptions of dementia search terms were chosen related to dementia and representation in film or artistic media and dementia and stigma search results were combined in endnote and duplicates were removed both authors independently reviewed the titles and abstracts for inclusion full texts of potentially eligible papers were obtained and independently reviewed with disagreements resolved through discussion the reference lists of included articles book chapters and relevant reviews were hand searched inclusion criteria original analysis on the representation or depiction of dementia in popular culture between 1970s and the present research paper and not a review book review or film review full paper and not abstract or poster published between 1989 and 2018 written in english data extraction descriptive data was extracted by one reviewer and checked by a second 1 authors date title and journal 2 material analysed 3 country of origin of materials 4 analysis methods a quality rating tool was not used as the criteria used to judge quality in health research are less appropriate indicators of quality in arts and media studies analysis thematic synthesis of the whole text of included papers was undertaken 82 using nvivo software both authors identified descriptions of dementia or themes and frames including values assumptions conceptualisations and cultural context underlying the semantic content as reported by paper authors initial descriptive themes were identified independently by the two researchers discussed and refined descriptive themes were jointly scrutinised to identify how dementia was being framed including the emotions elicited by those frames then all material was recoded into the agreed themes and frames saturation was reached with no new themes or frames emerging in later coded articles throughout the analysis we selfreflected and discussed our own assumptions and frames regarding dementia these included the impact of our experiences as a psychologist in dementia research and a health sociologist with minimal experience and preconceptions in relation to dementia results characteristics of included papers the search identified 37022 articles 95 full texts were obtained 59 articles were determined as eligible and an additional article was identified based on hand searching the main reason for exclusion during the title and abstract screening was that papers were not about the representation of dementia reasons for exclusion from fulltext results are depicted in fig 1 the cultural material examined in included papers were television and movies newspapers and television literature language and a mixture two papers included material produced by people with dementia and care partners 38 analysis methods included quantitative coding of how dementia was depicted used more commonly with news media 4060666770 framing analysis 2632636976 discourse analysis 71 and foucauldian analysis 75 quantitative studies were more likely to describe their methods whereas papers from arts and media disciplines were less likely to explicitly describe methodology hence some papers provided inclusion criteria or justification and context for the material which was chosen for analysis however many papers did not explain how or why material was selected the majority of articles were published in ageing or mental health journals with a few in sociological and humanities journals descriptive themes the descriptive themes were that ageing and old age is depicted concurrently with dementia dementia was often equated with alzheimers disease people with dementia were depicted as having memory difficulties being disoriented and experiencing decline and death treatments or cure were not typically shown and positive depictions of dementia occured rarely ageing and old age is depicted concurrently with dementia people with dementia were almost always portrayed as being old or ageing for instance kesslers 2012 quantitative analysis of 2604 photos in german weekly news magazines reported that judges rated 46 of characters with dementia as older than 80 years 43 as between 60 and 80 years and 29 as younger than 60 years 67 the characteristics of ageing portrayed in relation to people with dementia were physical social and psychological for example in their descriptions of newspaper images accompanying newspaper stories on dementia brookes et al wrote the hands … reveal not only conspicuous features such as bruises and liver spots but also creases and wrinkles in the skin and even the bones and joints beneath these are images of vulnerability 71 in books and film the decline with age of people with dementia was often emphasised through juxtaposition with more positive depictions of younger people sometimes their younger selves dementia is often equated with alzheimers disease papers showed that alzheimers was the most commonly depicted type of dementia 2734 and the media often used the terms dementia and alzheimers interchangeably or together the interchangeability of the terms dementia and alzheimers disease was also apparent in the research papers themselves the titles of 21 papers suggested that they focused on the depiction of alzheimers disease 26 27 29 32 35 38 39 42 43 46 53 6365 6870 72 77 80 83 however some of these used the terms dementia and alzheimers interchangeably the paper on alzheimers at the movies as an illustration included a film about margaret thatcher who had vascular dementia without mentioning this fact 42 other types of dementia were rarely mentioned in the reviewed papers of the 60 included papers vascular dementia was mentioned in two papers 5159 lewy body dementia in two papers 5166 and frontotemporal dementia in one paper 59 depiction of people with dementia memory difficulties were reported in every paper as a characteristic of people with dementia often presented as an early symptom foreshadowing future difficulties in the novel iris 25 this was shown as forgetting to come out with the right words she suddenly finds it difficult in front of a large audience to come out with the words to reply to questions something with which she has previously been quite at ease gerritsen et al 49 analysis of 23 fictional movies with a theme of dementia reports that 18 films showed memory problems and 10 showed word finding difficulties disorientation to time place or person was also commonly reported as a characteristic of people with dementia they were depicted as being confused thinking that the present is the past consequently they were not able to find their way out of familiar places not recognising familiar people and getting lost gerritsen et al 49 paper reported that 20 of 23 films showed disorientation to time place or people people with dementia were also depicted as acting outside social norms or in deviance 64 examples are walked into her office in pink pajamas and beige high heels 63 he cannot find his keys he gets a hammer and screwdriver and prises the front door open 25 and shigezo eats his wifes ashes in the middle of the night 41 in response to these behaviours others were shown as reacting with indifference shock anger aggression and by shaming them when grandma urinates on the carpet in his mothers living room murat his aunt and uncle respond with uncontrolled laughter 43 books and films about dementia almost all told a story of progressive decline and death ending in institutionalisation 25515283 or the death of the person with dementia 282934354143445153545880 many books and films depicted the progression of declining ability to comprehend the world and conduct selfcare flashbacks were commonly used to show the person earlier in their life emphasising losses and decline people with dementia were shown as wanting to die as a mother i just want to die while i still remember my son 41 or trying to kill themselves 31 correspondingly care partners were shown in constant bereavement 73 where the character with dementia was alive at the end of the story the suggestion is that this is still the end of that persons life narrative deaths got the only door code out of whernside ward 55 treatments or cure over 25 years of us television news treatment was the top issue comprising 192 of all coverage 65 people with dementia nonetheless were not shown typically shown as receiving treatments in a review of 23 movies only three characters are depicted as taking medications for dementia albeit not accurately 40 positive depictions of dementia there were reports of positive depictions of dementia though these were in the minority in terms of numbers of academic publications and mentions within those publications rather than suffering people with dementia were depicted as being happy 4650 sometimes having forgotten all the bad memories or responsibilities of life 3159 the most frequent emotional tone coded in 2012 photographs related to dementia from german weekly news magazines was positive followed by neutral and negative 67 people with dementia were shown as exercising agency in 12 of 23 movies the person with dementia is shown as having something to contribute socially 49 fictional characters were shown as solving crime cases 51 committing planned burglaries 52 starting new romantic relationships 4445 directing and performing in a play 44 people with dementia including in the later stages of dementia were shown as expressing love through words hugging kissing and other physical signs of affection 24364749 documentaries showed a prominent politician with dementia setting up a research foundation to research dementia and people with dementia performing in a choir 50 people with dementia were telling their own stories and by describing their own experiences contributing actively to discourse on dementia as well as demonstrating their personal agency and identity 3881 people with dementia were also depicted as personally growing in that they develop socially emotionally or spiritually 43 for instance they were dealing with grief at the loss of a spouse 59 overcoming prejudices 52 and embracing a previously rejected cultural heritage 39 the writings of people with dementia include descriptions relating their personal journeys and shifts in outlook about themselves and dementia 38 frames for dementia frames for dementia were typically negative including the biomedical natural disaster and epidemic military and fighting the living dead and burden of care frames dementia was also framed more neutrally with the alternative mindbody frame biomedical frame dementia was commonly explained as a biomedical disease involving brain deterioration this biomedical frame was often accompanied by digital illustrations of disintegrating heads or brains or neuroimaging scans which serve to depersonalise the disease and emphasises a reductionist biological viewpoint 71 dementia the disease was presented as a complex scientific puzzle that can only be addressed through research van gorp and vercruysse 76 describe this frame aligning with a community value of faith in science wherein we trust in science and commit funding to research which offers the promise of a cure the biomedical frame was prominent in news coverage with scientists or doctors often featuring as experts 6374 a review of 1393 news reports found that doctors and researchers were the most interviewed sources followed by patientsfamilies politicians and other supporters 65 natural disaster and epidemic frames natural disaster and epidemic frames were also commonplace in news coverage of dementia the rise in the global prevalence of dementia the disease was described as a force of nature which will overwhelm mankind terminology used includes rising tide dementia tsunami and silent epidemic 68767779 the dementia disaster is vast one of the greatest threats to humanity 33 and the disease of the century 77 within this frame people with dementia were labelled as sufferers of unspeakable horror passive victims of apocalyptic demography epidemic suggests that dementia is contagious 51 the natural disaster frame was often presented in conjunction with a biomedical frame with science to the rescue of the disaster military and fighting frames dementia was personified as a killer deadly claiming lives responsible for deaths inflicting a death toll kills slowly attacks speech and memory invades the brain strikes victims 7177 public campaigns relating to dementia were described in similarly militaristic terms obamas war on alzheimers alzheimers society leading the fight against alzheimers disease and fight dementia save australia 49547879 in personal stories people with dementia were sometimes represented as fighting their condition for instance in the spanish documentary bicicleta cullera poma former politician maragall was depicted as an extraordinary hero who struggles to beat dementia 50 although the language suggested that the world was at war against dementia the disease no examples were provided in included papers for victories in this war lane et al 78 suggested that the military metaphor may be unhelpful in that someone who was not winning their individual battle against dementia may be perceived as not fighting hard enough or failing the living dead frame people with dementia were depicted as the living dead consistent with the disease being a killer in entertainment and news media descriptions for dementia included death before death funeral that never ends social death psychological death already dead death that leaves the body behind vegetable there is nobody there and withered shells 2434636473 book titles included alzheimers disease coping with a living death and a curious kind of widow loving a man with advanced alzheimers 26 interestingly writing by people with dementia also included the living dead frame 38 following on from the notion that they are dead people with dementia were also described as subhuman self that unbecomes nonpersons not human 3577 she was just an animal an animal with a stomach to be filled to continue alive who needed to drink at least one litre of water a day who defecated and urinated … barba 2004 2567 cited in 55 the living dead frame was associated with a western cartesian hypercognitive view of the self western philosophy posits that mind and body were separate with the mind being the seat of identity when the brain mind deteriorated then the self deteriorated memories were a source of identity so as memories were lost then so was personhood without memory there are no experiences … there is nothing but void … the vacuum that is death 84 p 96 cited in 34 as people with dementia lost their minds they became crazy or mad even in cultures where mindbody dualism was not a dominant world view dementia was still seen as a form of madness such as in asian and middle eastern cultures chi dai zheng is the term for dementia used in china hong kong and singapore which has negative connotations of insane and idiotic 74 junun atah was an arabic term for dementia which would mean losing ones mind and for one to be acting in crazy ways 34 a corollary of being seen as the living dead was that the viewpoint of the person with dementia was usually not depicted an analysis of 25 articles on ad from high circulation canadian print magazines found that almost nothing was presented from the perspective of or about the needs of the person with dementia 63 consistent with people with dementia being depicted as not fully human they were also shown as not having selfdetermination analysis of 50 articles from british magazines found that articles presumed that people with dementia were not autonomous agents who could make decisions without external influence 60 in the films black daisies and mum participants did not give informed consent regarding their participation 4755 the ethics of releasing the film the iron lady and the novel iris while their central characters were still alive but not able to consent or comment have been called into question 4748 the reduction of the human rights in depictions of people with dementia included their right to life this hermeneutical injustice was evident in standard texts on dementia 51 people with dementia were shown as being killed by their loved ones in an act of beneficent euthanasia because they would be better off dead 77 in andrés barbas novel ahora tocad música de baile inés fonseca a character with later stage dementia was killed by her son the reader was left to judge whether she has been murdered assisted to die with dignity or sacrificed 35 burden of care frame the stories in the majority of films and books were about the impact of dementia on the relationship between the person with dementia and their families with the care partner sometimes depicted as the main protagonist 334780 a review of films found that most characters with dementia were unable to complete activities of daily living without assistance with care partners bearing the burden of care 40 care partners were shown doing housework tasks providing physical help with bathing eating and toileting and being on watch constantly 3275 care partners were depicted as in a constant state of bereavement for the person who is already lost to them 73 alongside the personal stories of caring were news descriptions of the economic and societal costs of care 80 media articles suggested there was a moral obligation to provide good care and that good care partners are brave selfsacrificial and heroic 607579 alternative frames a few articles discussed the representations of dementia within a counterframe of bodymind unity within this frame people with dementia engaged with the world through sensory and physical interactions and express themselves through their bodiesembodiment of experience so rather than having lost selfidentity and agency their identity emotional connections and influence on others were through the power of their bodies 5975 for instance in the picture book la abuela necesita besitos by ana bergua the grandmother with alzheimers disease kissed and hugged her granddaughters and is emotionally connected with them 32 interestingly this frame was shown in material from indian japanese and spanish cultures in japan selves are understood to be formed out of interactions with others exemplifying the socalled relational or sociocentric self furthermore in japan the self is understood to be defined not so much by ones cognitive acuity but more by the embodied habits that allow the graceful performance of socialised selfhood 59 feelings elicited by dementia depictions the way dementia was depicted and framed elicited negative emotions and a sense of social distance between people with dementia and the audience negative emotions the common frames for dementia were depicted in association with negative emotions fear was the most common emotion associated with dementia for instance in relation to the living dead frame 26 news reports described or implied that the public should be fearful of dementia the disease sometimes with an undercurrent of hysteria 79 in books and film people with dementia and care partners were shown as frightened of the diseasethey fear of loss of abilities independence memories themselves relationships and the unknown at night when it is total blackness these absurd fears come the comforting memories cant be reached davies 1989 cited in 24 shame was another emotion commonly shown in association with dementia people with dementia were represented as ashamed of having dementia 283448505177 though the moral premises underpinning shame was not clear he is not dying of alzheimers disease hes dying of shame guilty pity and compassion were other feelings related to dementia care partners were sometimes depicted as feeling guilt in relation to the care they provided or were expected to provide 253560 pity and compassion were suggested as being elicited in relation to dementia 3171 social distance academics wrote that the way dementia was depicted increased affective and normative social distance affective social distance was higher when we felt less sympathetic understanding towards another normative social distance was higher when distinctions between us and them were felt more strongly 85 the biomedical and living dead frames for dementia distinguished between healthy and diseased brains and human and subhuman emphasising the otherness of people with dementia this difference was increased through other ways for instance in stock photographs of people with dementia commonly used in the press images were selected in which the people with dementia were looking away from the viewer or depicted as a set of disembodied hands which reduced the possibility for emotional connection 71 depictions of dementia which highlighted the oddities of their social behaviour also create a sense of distance 79 the stories were not told from the viewpoint of the person with dementia 63 which also reduced the ability of the viewer to relate to people with dementia discussion this review found that the prevalent cultural depictions and frames around dementia were negative the stereotypical depiction of a person of dementia was of an old person with alzheimers disease who loses their memory mind and identity behaves unpredictably and is suffering this stereotype was framed so that the person is not fully human and does not have a voice the societal narrative was that dementia is an overwhelming medical epidemic that brings a burden of care onto individual families societies and governments the predominant emotion associated with dementia was fear dementia was usually depicted in a way that generated social distance between those with dementia and the audience us and them these depictions of dementia are consistent with stigma as observed or expressed in the public health professionals and people with dementia 86 the public is afraid of dementia health professionals treat people with dementia with less respect after diagnosis and people with dementia experience othering in society 187 these findings support the use of dementia language guidelines that suggest avoiding words like sufferer and demented dementia old age and symptoms of mental illnesses were regularly codepicted people with dementia may be additionally stigmatised because of this intersectionality ageist views are were that older people do not contribute and are a burden mental health stigma includes stereotypes of violence and incompetence 89 this review found that there were positive depictions of dementia though these were less common people with dementia were shown to be happy exercise agency and experience personal growth people with dementia were represented within a mindbody unity frame consistent with notions of personhood and embodied selfhood 90 other counterframes for dementia are that dementia is a natural part of ageing carpe diem family reciprocity of care and a moral duty to provide loving care 76 dementia friendly communities present a positive frame by showing people with dementia actively participating in the movement the dementia friendly approach has been shown to reduce stigma 91 other participatory approaches where people with dementia are seen as equal and active participants in the project have been shown to reduce stigma in others involved 92 dementia awareness campaigns should be considering and testing how dementia is framed within campaign messages in order to decrease stigma the impact of positive frames on dementia stigma need to be investigated further strengths of this paper are that we took a systematic approach to synthesising findings from papers that used arts and health methodologies and that analysed a range of cultural media it allowed us to produce a broad novel systematic description of cultural stigma of dementia however some of the papers were difficult to include within our review approach for instance many of the included papers did not explicitly state how material were selected or their analysis approach as this is not a convention in arts research this made critique and commentary on methodology difficult we were not able to analyse differences over time in cultural depictions or differences in depiction by media type genre and styles this kind of analysis was not possible due to the heterogeneity in the papers in the media types described and countryculture further the review was limited to english language papers and has a western bias although there were some papers describing nonwestern cultural media future research may be able to link the depiction of dementia directly to measures of dementia stigma it could also include searching of the arts and humanities literature investigating depictions of dementia in social media and blogs framing analysis crossmedia and crosscultural comparisons and investigation of changes in depictions over time it would be helpful if future papers on depictions of dementia were contextualised within cultures and analysis approaches were explicitly stated experimental studies might test the depiction of dementia using alternate frames and the impact of exposure to these frames on attitudes feelings and intended or actual behaviour towards people with dementia research also needs to be conducted on how to influence media portrayals of dementia the way that health and social care practitioners frame dementia during clinical and support interactions might impact on how people with dementia and care partners see themselves this needs further investigation the influence scientists and health professionals discourse in popular culture on dementia stigma could also be investigated conclusion in conclusion depictions of dementia in popular culture including how dementia is framed may influence dementia stigma and needs to be considered when working to decrease dementia stigma when talking about and depicting people with dementia we need to be mindful about the social impact of the words images and messages that we use i repeat please dont call us sufferers 93 abbreviation ad alzheimers disease contributed to the discussion and conclusion fp assisted lfl with endnote references all authors read and edited the paper the author read and approved the final manuscript authors information leefay low phd is associate professor in ageing and health and head of behavioural and social sciences in health in the faculty of health sciences university of sydney she is a registered psychologist with a phd in psychiatric epidemiology aprof low conducts research that she hopes will make a difference in the world her main areas of expertise are in home and residential care for older people wellbeing in people with dementia dementia risk factors for dementia dementia literacy and people from culturally and linguistically diverse backgrounds she is particularly interested in developing and evaluating interventions to improve the quality of life of older people she has methodological skills in population studies systematic reviews clustered randomised trials instrument development and evaluation and translation of research into practice she has authored over 90 peerreviewed articles six book chapters as well as two books on dementia she is an active advocate in improving how older people are treated and cared for leefay thinks that research is great fun and even admits to liking statistics second author dr phil farah purwaningrum is honorary associate at school of social and political sciences the university of sydney farah is a sociologist with an interdisciplinary background in law she attained her phd from rheinische friedrich universität bonn germany in december 2012 she has a keen interest in research areas of the sociology of health comparative studies and sociology of knowledge in these research areas her papers have appeared in international peerreviewed journals such as international journal of health governance international social science journal south east asia research the international journal of health planning and management international sociological association e symposium she is a steering board member of international sociological association research committees rc15 on sociology of health and rc no 57 on visual sociology ethics approval and consent to participate not applicable competing interests the authors declare no competing interests

background literature film and news media reflect and shape social perceptions of dementia which in turn impact on dementia stigma the aim of this paper is to systematically review papers on the depiction and frames for dementia in literature film mass media and social media in order to better understand cultural stigma related to dementia methods a systematic search of electronic databases was undertaken combining phrases relating to dementia popular culture and representations and phrases relating to dementia and stigma we searched for scientific english language papers which included original analysis on the representation or depiction of dementia in popular culture ie in film and television literature news social media and language articles published between 19892018 were included the search was conducted in december 2017 and updated in january 2019 inductive thematic synthesis was undertaken results a total of 60 articles were included from an initial sample of 37022 dementia was almost always depicted in conjunction with ageing and often equated with alzheimers disease common frames for dementia were biomedical dementia involves the deterioration of the brain for which there is no current cure natural disaster or epidemic dementia is a force of nature which will overwhelm mankind and living deadpeople with dementia lose their brains memories minds and consequently their personhood and human rights there were examples of more positive depictions of dementia including expressing love and individual agency and experiencing personal growth feelings commonly associated with dementia were fear shame compassion and guilt and depictions often resulted in a sense of social distance conclusions depictions of dementia in popular culture are associated with negative images and feelings and social distance between people with dementia and those without these correspond to dementia stigma in the public and as experienced by people with dementia further research is needed into the impact of literature news and social media on dementia stigma and these cultural mediums might be used to reduce stigma

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introduction in subsaharan africa an estimated 225 million adults and children live with hivaids and an estimated 33 of the general population suffers from malnutrition the convergence of hivaids and undernutrition results in feedback cycles with each amplifying the consequences of the other hiv infection contributes to undernutrition by impairing metabolic function and causing malabsorption poor storage and utilization of nutrients and increased infections especially diarrhea reciprocally inadequate nutrition accelerates the spread of hiv through increased risk of hiv exposure and infection while also undermining antiretroviral treatment adherence as patients express fears of developing the side effect of increased appetite without enough food to eat low body mass index may reflect both hivaids disease progression and undernutrition critically low bmi strongly predicts mortality independent of cd4 lymphocyte counts at the time of diagnosis and enrollment depression has been shown to be associated with reduced dietary intake in adults living with hiv however the relationship among socioeconomic demographic and selfreported health factors in predicting bmi at enrollment in hiv care programs represents a critical link in understanding the relationship between nutrition and hiv that has not yet been well characterized as a result of the critical relationship between bmi hivaids disease progression and healthrelated outcomes understanding the factors associated with low bmi at enrollment into hiv care can usefully guide treatment and supportive care as well as provide information about targeting and recruiting potential patients this study focuses on nyanza province the province with the highest hiv prevalence in kenya at 139 therefore in this study we examine socioeconomic demographic and disease progression markers associated with low bmi among newly enrolled persons living with hivaids in nyanza province kenya to our knowledge this is the first study to examine sociodemographic factors associated with bmi at enrollment in care among adults living with hivaids in subsaharan africa materials and methods study population between january 2005 and march 2010 14925 persons living with hivaids enrolled in 31 clinics through the the family aids care and education services program a collaboration between the kenya medical research institute and the university of california san francisco in nyanza province kenya for this crosssectional study we searched the faces programs openmrs electronic medical record for all adult patients enrolling into care criteria for eligible study participants included being over the age of 15 and enrolling at a faces clinic the study was approved by the ethical review committee at kemri and the committee on human research at ucsf data collection at all facessupported sites trained community and clinic health assistants enrolled patients and collected sociodemographic information including age gender marital status highest level of education and household size using a standardized intake form in addition three selfreported quality of life measures were obtained during enrollment related to health status daily activity impairment and feeling down or sad in the past four weeks for the latter question patients were asked how much time during the past four weeks have you felt down patients height and weight cd4 tcell count and world health organization adult staging category were also determined at enrollment statistical analysis statistical analyses were conducted with spss 120 for windows demographic and anthropometric characteristics between women and men were compared using independent samples ttests and pearsons chisquare tests univariate logistic regression analyses were performed for underweight with each independent variable multivariate logistic regression models included all explanatory variables age household size education marital status cd4 who stage health status health limiting daily activities and feeling down all variables were checked for multicollinearity and had a variance inflation factor 2 we calculated 95 confidence intervals for all odds ratios and reported the p value for the associated logistic regression coefficient all p values were twotailed with the level of significance set at p 005 results of the 4409 men and 10256 women who enrolled in facessupported clinics between 2005 and 2010 anthropometric data were available for 3533 men and 8254 women there were no significant differences in household size educational attainment marital status or cd4 count among respondents with and without available anthropometric data however among women only the mean age of those without anthropometric data was slightly older the mean bmi was 211± 39 for women and 197± 29 for men overall 274 of patients who had enrolled in care were underweight with more men being underweight than women the mean age at enrollment was 309 in women and 362 in men the highest level of education for most women and men was primary school the mean cd4 count at enrollment was significantly higher among women than men among adults enrolling for hiv care age education cd4 count who stage selfreported health status and selfreported health limitations in daily activities were strongly associated with underweight in univariate and multivariate analyses we found no significant associations between underweight and household size marital status or feeling down or sad in the past four weeks in multivariate models in terms of demographics compared to women 50 or older the adjusted odds ratios for underweight increased from 103 for women 4049 to 290 for women aged 1519 this suggests that younger women are more likely to present as underweight as compared to older women similarly compared to men 50 or older the aor for underweight were 587 for men aged 1519 compared to women whose highest level of education was college or university the aor for underweight increased from 229 for women with some secondary education to 460 for women with no formal education as for the health characteristics significantly associated with underweight persons with a cd4 count less than 250 cellsmm 3 had a 213 increased aor among women and a 143 increased aor among men of being underweight compared to adults with a cd4 count 750 cellsmm 3 or higher compared to women with who stage 1 the aor for underweight increased from 171 for women with who stage 2 to 348 for women with who stage 3 and 366 for women with who stage 4 with similar findings among men adults who reported poor health had nearly a 2fold increased risk among women and a 10fold increased risk among men of underweight compared to adults who reported excellent health compared to adults who felt no limitations in their daily activities due to health the aor for underweight was 244 among women and 244 among men who felt health limited their daily activities a lot discussion overall 274 of adults enrolling in facessupported clinics in nyanza province had a bmi 185 in both sexes low bmi at enrollment was significantly associated with younger age less education decreased cd4 count advanced who stage poorer selfreported health status and selfreported health limitations in daily activities at enrollment men were older and presented with lower bmi lower cd4 count and more advanced who stage than women the prevalence of underweight in this population is higher than the general population in nyanza province where 88 of women were reported to have a low bmi which may be reflective of higher food insecurity and poverty levels among persons living with hivaids the high prevalence of underweight may also suggest that hivassociated wasting may have progressed significantly by the time of enrollment in hiv care the trend of late enrollment may be more pronounced in men due to the relative unacceptability for males to seek help and underdevelopment of health services tailored to men compared to reproductive and child health services tailored to women younger age was significantly associated with lower bmi among both sexes adolescents and young adults may be at increased risk for underweight from decreased food allocation due to their low household status and increased energy expenditure from work and household obligations however these explanations are mainly speculative given limited data and therefore an important area of future research individuals with higher education levels may seek health services earlier or have a higher income allowing for the purchase of sufficient food and health care which may account for their better nutritional status education at all levels including at schools and at the community level have long been identified as central to addressing the hiv epidemic poor selfreported health status and greater selfreported activity impairment were associated with underweight for both men and women living with hivaids men reporting poor health status the strongest predictor of underweight were nearly ten times more likely to be underweight than men reporting excellent health status adults living with hivaids appear to be aware of their poor nutritional status and the degree of progression of their illness which may also contribute to their poor nutritional status future research could further explore the contributions of mood and substance issues such as alcohol and drugs to poor nutritional status and the directionality of illness progression and patients understanding of their illness as expected low bmi was significantly associated with lower cd4 count and higher who stage indicating that being underweight is correlated with hiv disease progression in our study population this studys crosssectional design precludes any causal inferences not all patient charts were complete which accounts for the missing data in addition although useful for international comparison bmi contains some documented limitations in measuring body fat percentage visceral adipose tissue and central obesity particularly among noneuropean populations high levels of undernutrition may have been related to communitylevel factors as well as hiv disease however the large sample size including both urban and rural populations and similar rates of undernutrition reported in western province kenya and the rest of subsaharan africa supports the generalizability of this studys bmi findings in summary this study adds to the literature by identifying male gender younger age and lower educational attainment as key determinants of poor nutritional status at enrollment in hiv care to our knowledge this is the first study in subsaharan africa to examine the sociodemographic factors associated with bmi among adults living with hivaids at the time of enrollment in care conclusion given that low bmi at enrollment is associated with higher mortality and poorer health outcomes independent of cd4 count it is imperative for patients to enroll into hiv care before their nutritional status significantly declines over a third of men and a quarter of women in nyanza province enroll into hiv care with a bmi 185 indicating significant progression of wasting and decline in nutritional status males particularly enroll with poorer nutritional status older age and more advanced disease progression making them a key population to encourage for earlier enrollment through voluntary counseling and testing community hiv testing campaigns hiv education and stigma reduction adolescents are also at increased risk to enroll with poorer nutritional status therefore school or communitybased programs targeting this population should be promoted future research could further clarify the mechanisms by which adolescents are more likely to enroll with low bmi furthermore interventions to directly improve the nutritional status of underweight persons and structural interventions that improve food access such as agricultural production projects may be imperative to the overall success of hivaids and nutrition support programs

low bmi at time of enrollment into hiv care has been shown to be a strong predictor of mortality independent of cd4 count this study investigated sociodemographic associations with underweight bmi 185 among adults in nyanza province kenya upon enrollment into hiv care bmi sociodemographic and health data from a crosssectional sample of 8254 women and 3533 men were gathered upon enrollment in the family aids care and education services faces program in nyanza province kenya between january 2005 and march 2010 overall 274 of adults were underweight upon enrollment in hiv care among both women w and men m being underweight was associated with younger age w adjusted odds ratio aor 290 95 confidence interval ci 185455 m aor 587 95 ci 2801232 for age 1519 compared to ≥50 years old less education w aor 292 95 ci 183465 m aor 155 95 ci 104231 for primary education compared to some collegeuniversity low cd4 count w aor 213 95 ci 150303 m aor 143 95 ci 076270 for 0250 compared to ≥750 cellsmm 3 and poor selfreported health status w aor 172 95 ci 089333 m aor 978 95 ci 1267573 for poor compared to excellent male gender lower educational attainment younger age and poor selfreported health are associated with low bmi at enrollment into hiv care in nyanza province hiv care and treatment programs should consider using sociodemographic and health risk factors associated with low bmi to target and recruit patients with the goal of preventing late enrollment into care

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introduction demographic projections indicate that about two billion people will be aged 60 years or more in 2050 of these 80 will be living in middle and low income countries which will represent a challenge to the organization of urban space health services and other public policies in these locations 1 among the main implications arising from the accelerated aging process the increased incidence of chronic diseases and consequently the years spent with disabilities should be highlighted 2 disability in the elderly is usually determined based on the difficulty or inability to perform daily activities independently these activities can be classified into basic activities of daily living related to selfcare and instrumental activities of daily living related to the tasks of social independence 3 brazilian data for 2013 showed that 68 and 173 of seniors reported little difficulty to perform at least one badl and one iadl respectively 4 as for incidences 178 of seniors monitored over a period of three years in são paulo developed disability in up to two activities 5 according to the international classification of functioning disability and health 6 among factors that may contribute to occurrence of disability are personal factors such as sex and age and environmental factors including characteristics of place of residence in systematic review 7 it was found that contextual factors such as lower income of neighborhood or surroundings are associated with higher chances of disability in badl and iadl in adults and in the elderly the main hypotheses relate to the fact that lower income neighborhoods provide few opportunities for social interaction between residents 89 and higher difficulties of access to health services 10 which contributes to social isolation illness and consequent loss of the ability to perform activities of daily life however these findings do not necessarily reflect the reality of the brazilian context since the samples used in the review study comprised mainly american and european subjects whose countries present better socioeconomic characteristics than those observed in brazil in addition most studies on the subject present crosssectional design in brazil we found only two studies that investigated the incidences of disabilities in activities of daily life 511 and none that analyzed longitudinally the association of different contextual income strata with their occurrence disability is an important marker in the health of the elderly population not only because it reflects their worse general health condition but also because it substantially raises their risk of mortality 12 therefore findings related to the influence of modifiable risk factors on the occurrence of disabilities such as neighborhood income become important to contribute to actions that seek the extension of longevity with independence thus this study aimed to i evaluate the incidences for badl and iadl over four years and ii estimate the association between contextual income and incidences observed in seniors living in florianópolis state of santa catarina brazil methods this is a household populationbased study with longitudinal design using data from the epifloripa elderly cohort which investigates the living and health conditions in representative sample of elderly individuals residing in the urban area of the municipality of florianópolis state of santa catarina brazil the sample of this study was composed of seniors of both sexes aged 60 years or older not institutionalized participants of the baseline and of the first followup of the cohort of the 1705 seniors interviewed in baseline 1196 composed the final sample of the first followup a total of 702 of response rate in addition to the deaths determined in the mortality information system we considered as followup losses all seniors not found after four attempts of interview who were currently hospitalized or who had moved out of the municipality refusals included seniors who refused to answer even after being visited at home data was collected using inperson interviews in the homes of the elderly applying the questionnaire using personal digital assistants and netbooks data consistency was assessed weekly during collection periods and quality control showed satisfactory to good consistency at the two times with kappa index values between 06 and 09 and between 05 and 09 further details about the methodological and cohort sampling procedures are found in another publication 13 the outcomes investigated in this study were the incidences of badliadl disability evaluated using the instrument multidimensional functional assessment questionnaire validated in brazil 14 the questionnaire investigates the degree of difficulty in performing six badl and nine iadl incidence was estimated as described below • incidence of disability in badl presence of little or great difficulty or disability to perform at least one of the six badl investigated in the followup considering seniors that presented no disability in the two domains or that presented only in iadl in baseline • incidence of disability in iadl presence of little or great difficulty or disability to perform at least one of the nine iadl investigated in the followup considering seniors that presented no disability in the two domains or that presented only in badl in baseline the main exposure was contextual income which indicates the per capita income value of residents of permanent households in the census tracts sampled in the study estimated using the aggregated data provided by the 2010 brazilian demographic census 15 and subsequently categorized into terciles individual adjustment variables were selfreported during the followup and included sex age equalized per capita household income and time of residence in the neighborhood analyses employed the statistical software stata version 140 we described the incidence of the outcomes and their confidence intervals according to the exposure variable and individual adjustment variable data analysis employed multilevel logistic regression first we tested the null model and then we included the other variables according to three models model 1 only with the census sector per capita income variable model 2 adjusted for sex and age and model 3 adjusted for individual per capita income we estimated the values for odds ratio and the respective 95 ci of the associations considering individual variables as first level of analysis and census tracts as second level for each model we estimated the intraclass correlation coefficient which provides estimates of the total variance of the outcome that can be attributed to the differences between census tracts icc value was defined by the following formula all respondents signed an informed consent form in the two phases of the study results the sample effectively analyzed comprised 1196 seniors who answered questions about the badl and iadl at both phases of the cohort study mean age of followup participants was 739 years with higher proportion of female we observed significant followup losses in the sample only for the age group variable with higher proportion of deaths among seniors aged 80 years or more for the other socioeconomic variables analyzed sex and individual per capita income losses were equivalent between the categories analyzed the incidences of disability were 158 in badl and 134 in iadl after the fouryear followup period for females we observed slightly higher incidences in both domains as for age group the highest incidences were observed in badl for seniors aged 80 years or more and in iadl for those aged 7079 years seniors belonging to the lower individual per capita income tercile showed higher incidence of disability in badl while in iadl no difference was observed between the lower and the higher tercile the contextual per capita income median was brl 1291 ranging from brl 383 to brl 5046 incidence of disability for both badl and iadl were higher in the lower terciles of the distribution in comparison between the groups the elderly who acquired disability in the followup resided in census tracts with lower percapita income median than those that did not develop disability table 2 presents results of multilevel logistic regression for incidence of disability in badl both in the raw analysis and in the analyses adjusted for individuallevel variables we observed significant associations between the intermediate contextual per capita income tercile and the incidence of the outcome the chance of developing disability in badl was 37 lower among seniors residing in sectors with intermediate per capita income tercile than those living in the lower tercile and although not significant we observed that the elderly residing in the high per capita income tercile also presented lower chances of developing disability in badl than those in the lower tercile table 3 shows results observed for incidence of disability in iadl in this outcome we observed no statistically significant associations between the contextual per capita income terciles we also found that for both outcomes icc values had minor variations between the models analyzed which suggests that the contextual per capita income variable contributed very little to explain the variance of the outcome between the levels of analysis discussion in this study the incidence of disability among sampled seniors was 158 in badl and 134 in iadl after a fouryear period although disability is considered one of the key markers of elderly health longitudinal data about its occurrence in activities of daily living are still scarce in the literature especially in populations of medium and low income countries which hinders the conduct of comparisons we found two studies with brazilian elderly in the epidoso cohort study in the municipality of são paulo the incidence of functional loss in seven or more badl or iadl was 178 after three years 5 while among the elderly in the sabe study also held in são paulo the density of incidence of disability in iadl was 4471000 personsyear for women and 2521000 personsyear for men after sixyear followup 11 international studies in american seniors found incidence of 25 in badl 17 and 48 in iadl 18 in separate followup periods that ranged from three to nine years respectively in another study that followed the elderly of the epese project the incidence of severe disability in three or more badl or iadl was 68 after five years 19 while in the oneyear followup with icc 040 000 000 000 longlived elderly the incidence of disability in activities of both domains was even higher 20 in general despite disparities observed in methodologies of the studies analyzed especially as to categorization of outcomes and sample followup period the findings indicate a tendency in the development of disability proportions rise as age increases with higher incidences usually observed in iadl than in badl in younger elderly especially because performing the first requires fine motor skills and preserved mobility which tend to be undermined early in the aging process 21 as for differences between the sexes we observed higher prevalence of disability among females 2223 however incidence is similar in both sexes 12 this result was also observed in this study in which the difference in incidence of disability between men and women was minor especially in iadl with 129 and 136 respectively as for influence of contextual neighborhood income on incidence of outcomes the elderly living in intermediate income tercile had 37 lower chance of developing disability in badl than those living in the lower tercile even after adjusting for individual variables most published studies that analyzed the association of neighborhood socioeconomic position with presence of disabilities present crosssectional design 81024 which limits direct comparisons however the findings in most of these publications are close to this study in which the elderly evaluated that lived in areas of greater socioeconomic advantage had lower chances of disability in badl of the two longitudinal studies found 925 statistically significant differences were observed only in one in which chinese elderly who lived in neighborhoods with higher per capita gross domestic product value showed higher chances of developing disabilities in badl than those living in neighborhoods with lower gdp values 9 however we consider that such finding differs from that found in this study because despite significant association was observed only in the middle income category the chances of occurrence of disability among the elderly of the high tercile were also lower than those of the lower tercile therefore we believe that residing in municipality sectors with higher income appears to reduce the development of disabilities in badl the main theories that support these associations are based mainly on the fact that more economically disadvantaged locations provide less access to and few options of services to the local community which minimizes the social interaction and support between residents and thus contributes to the development of disabilities 89 original studies 526 and metanalysis studies 27 that investigated the effect of social support on disability indicate that performing active leisure activities and socializing with friends and neighbors provide fundamental relations of cooperation and interactivity and help keep some skills preserved such as memory and spatial attention considered critical to performing activities of daily living independently in addition neighborhoods with greater social deprivation reflect smaller network of contacts and in some ways restrict social relations intensifying the bond with the family and consequently the dependency for performance of basic activities of daily life 24 there is also evidence that participation in community groups increases the access of older persons to information on health prevention and care as well as provides positive effects on selfesteem and satisfaction with life encouraging them to keep themselves independent 28 it is believed that the absence of association between contextual income and occurrence of disability in iadl may be related to the fact that performance of these tasks depends on characteristics involving the built environment that although most times are related to socioeconomic conditions of the place were not directly evaluated in this study some of these characteristics include the presence of quality streets and sidewalks and availability of accessible physical spaces green areas and leisure spaces that promote active behavior and greater participation in the community 2425 thus helping in keeping the independence of the elderly in activities outside the home the challenges faced by researchers on this subject include the use of contextual data from national surveys which often do not reflect the actual space of the neighborhood of the researched sample 29 in this study the geographical area was delimitated by the census tracts which is not necessarily equal to the neighborhoods physical space or to the social interaction area used by the seniors another limitation observed in this study as to the use of secondary data refers to the absence of socioeconomic variables in addition to income that could be analyzed to represent the context however we present potential that should be highlighted to our knowledge this is the first study with longitudinal design conducted in brazil that sought to investigate the incidence of disabilities in badl and iadl in a sample representing the elderly population and the influence of living in environments with different income strata on their occurrence the results can contribute to the planning of local and intersectoral initiatives with focus on reducing socioeconomic inequities aiming at income redistribution and above all at promotion of social inclusion activities for the elderly population that resides in the lowerincome sectors of the municipality another characteristic that should be highlighted refers to the separate analyses of the two outcomes that represent disability which is important since the loss of independence in these domains tends to occur in different ways as age increases neighborhood income having been associated only with badl shows greater urgency of investments in prevention initiatives since these basic activities represent disability in its most severe form being normally affected after iadl also concerning the study methodology it should be noted as a positive point the absence of significant losses of seniors between the two waves according to the variables studied except for the age variable which presented higher loss of seniors aged over 80 years due to deaths in this category 13 based on the results we conclude that the elderly living in census sectors with intermediate contextual income tercile have lower chances of developing disability in badl over four years than those of the lower tercile we consider important that new followups are carried out to estimate the incidence of disabilities among the brazilian elderly and the influence of living in neighborhoods with different socioeconomic positions on their development aiming at obtaining data that enable better comparisons and assist in public decisionmaking concerning the necessary interventions finally we highlight that the country is experiencing a period of great social political and economic challenges related to the accelerated increase in the number of elderly individuals and should therefore consider this population as priority in strategies involving the promotion of functional independence conflict of interest the authors declare no conflict of interest

evaluate the association between contextual income and the incidence of disability in basic and instrumental activities of daily livingthis is a cohort study with sample of elderly individuals n 1196 residing in florianópolis state of santa catarina brazil the incidence of disabilities was evaluated using reports of difficulty or inability to perform six basic activities of daily living and nine instrumental activities of daily living after four years contextual income was obtained from the 2010 census we conducted multilevel logistic regression analyses with adjustment models for individual variablesthe incidence of disability in basic activities of daily living was 158 95 ci 138179 and in instrumental activities of daily living incidence was 134 95 ci 116155 we observed significant association between contextual income and incidence of disability in basic activities of daily living having as reference the elderly living in the lower income tercile those who lived in the intermediary terciles and in that of highest income had 37 95 ci 041096 and 21 95 ci 052119 lower chances of developing disability respectively for the incidence of disability in instrumental activities of daily living we observed no statistically significant associationscontextual income influences the development of disability in basic activities of daily living in the elderly and should be the subject of actions to reduce socioeconomic inequalities and promote longevity with independence

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introduction smoking is the leading preventable cause of many diseases and deaths worldwide it is an important risk factor for diseases such as cardiovascular and pulmonary diseases and different types of cancer although a majority of smokers are aware of the increased risk of premature death due to smoking they are less likely aware of its harmful effects in causing disability and a reduction in quality of life 1 in addition studies have shown that smoking is strongly related to ocular diseases including agerelated macular degeneration cataract graves ophthalmopathy and glaucoma 2 agerelated macular degeneration and cataract are the leading causes of blindness worldwide 34 more importantly although many people are aware of the association between smoking and diseases such as lung cancer heart disease and stroke only a few are aware of its association with blindness 56 in a crosssectional study conducted at general hospital in the united kingdom between may and june 2004 only 12 of eye clinic patients and 7 of other clinic attendees believed smoking causes blindness however 70 85 and 90 believed that smoking causes stroke heart disease and lung cancer respectively 7 another study conducted in canada the united states the united kingdom and australia between 2004 and 2007 found that the knowledge that smoking could cause blindness varies across countries 130 in canada 95 in the united states 97 in the united kingdom and 472 in australia believed that smoking causes blindness 8 in saudi arabia the number of smokers is continuously increasing according to two studies conducted in 2013 and 2018 the prevalence of smoking among the saudi population increased from 122 in 2013 to 214 in 2018 910 furthermore according to a systematic review and metaanalysis conducted between 2010 and 2018 the prevalence of smoking among saudi college students was higher than in most regional countries 11 according to a study conducted among university students in abha saudi arabia only 348 of the participants were aware of the impact of smoking on diabetic retinopathy progression 12 however there are limited studies investigating the association between smoking and blindness in saudi arabia this study aimed to determine the awareness level among the young saudi population of the association between smoking and blindness materials and methods this is a descriptive crosssectional study conducted among the young population of saudi arabia a selfadministered questionnaire including sociodemographic data education level and smoking status was distributed using an online platform it also investigated the awareness and fear of blindness for three established smokingrelated diseases lung and heart diseases blindness and melanoma and the likelihood that smokers would quit on developing early signs of each condition we added the distractor factor to decrease the number of overreporting questions related to blindness the calculated sample size was 382 young participants the following statistical formula was used to calculate the representative sample size based on the study population young male and female participants aged 10 to 34 years from all regions of saudi arabia were included in the selection criteria participants 10 years or 34 research years of age anyone outside saudi arabia and those who fail to complete the questionnaire were excluded from the study ethical approval was obtained by the institutional research board and the ethics committee of king faisal university in alahsa after fulfilling all the needed ethical issues categorical variables were summarized as frequencies and proportions continuous variables were presented as means and standard deviations for comparison the chisquare test and mannwhitney u test were applied normality tests were performed using the shapirowilk test a pvalue of 005 at 95 ci was considered statistically significant data were analyzed using statistical packages for social sciences version 26 results the participants sociodemographic characteristics in accordance with their smoking status are shown in table 1 study data overall n table 1 sociodemographic characteristics of participants according to smoking status in this study the most common age group was 2125 years with females being more dominant than males regarding the participants education the majority held a bachelors degree or higher regarding residence location 238 lived in the northern region while 217 lived in the eastern region furthermore the prevalence of smoking was 187 and it was more common among the age group 2125 years males bachelor or higher degree holders and those living in the central region of saudi arabia regarding the participants smoking behavior 555 smoked one packet of cigarettes per day of them the smoking duration ranged from one to five years in 355 the participants were definitely or probably aware that the most common condition associated with excessive smoking was lung cancer followed by heart disease and stroke whereas the least associated conditions were melanoma and blindness one hundred and nine smoking participants believed that smoking would definitely or could probably cause lung cancer 108 believed that it could cause heart disease 100 indicated strokes 97 indicated melanoma and 86 indicated blindness condition smoking status nonsmoker n smoker n table 3 proportion of participants who believe that smoking definitely or probably caused conditions when comparing the ratings for the least or most feared condition between smoking and nonsmoking participants the results revealed that nonsmoking participants have higher ratings of fear that smoking could cause lung cancer heart disease stroke blindness and melanoma when measuring beliefs on whether or not smoking can cause blindness according to the participants smoking status and demographic data we found that the number of male participants who believed smoking could probably or definitely cause blindness was statistically significantly higher than female participants while the differences in age group an education level and residence region did not reach statistical significance condition discussion this study attempts to evaluate the awareness of blindness related to smoking among the young age population to our knowledge this is the first study in saudi arabia to have examined the knowledge of the young population regarding the link between smoking and blindness findings of this showed that 81 of the smokers and nonsmokers thought that smoking can definitely or probably can cause blindness lower than the awareness they had about other conditions associated with smoking such as lung cancer heart disease and stroke interestingly 913 of the sample population rated the distractor variable melanoma as a complication of smoking with higher ratings than blindness this indicates the need for awareness campaigns to educate young people about the specific diseases associated with smoking a study performed by kennedy et al 8 documented that the knowledge of smoking causes blindness was higher among the adult population in australia however fewer people from canada the usa and uk believed that blindness is a complication of smoking respondents further believed that secondhand smoke was the most dangerous one as it may cause cancer and stroke consistent with these findings handa et al 13 indicated that 425 of the eye patients were aware of the link between smoking and irreversible blindness but they had shown better awareness about the association between smoking and lung cancer comparable to the reports published by bidwell et al 14 as well as moradi et al 15 however in a crosssectional study by dawood et al 16 iraqi smokers showed poor awareness regarding some risk factors of smoking such as lung cancer in nonsmokers impotence in male smokers premature aging and stroke adding that extensive efforts are needed to raise awareness about the risk of smoking and health benefits of smoking cessation there have been many reports that lung cancer heart disease and stroke were the most common complications resulting from smoking however blindness due to smoking seems to be not being recognized by the population such that even in some of the first world countries like canada the usa and the uk smokers are less likely to know that smoking causes blindness 8 in our study male smokers are more likely to know that smoking can definitely or probably cause blindness in singapore 13 however there was no association between awareness of smokingrelated blindness among gender and races but authors noted a better awareness about the link between smoking among heart attack stroke and other lung diseases could be more associated with a better knowledge of smokingrelated blindness data in our study also suggest that stroke lung cancer and heart disease were the most feared complications of smoking but they exhibited less fear of blindness while the distractor disease has a mean of 354 with nonsmokers were more feared of having all these conditions than smokers were these findings seemed to be not following the report of moradi and colleagues 15 where they found out that the patients were more fearful of blindness than of lung cancer heart disease and deafness on the contrary bidwell et al 16 reported that adult patients were less likely to be fearful of blindness than lung cancer heart disease and stroke in a study conducted by oncken et al 1 the general population reported that the perceived risk of smoking could be more associated with premature death and there were 635 believed that smoking was also linked to disabilities with the knowledge and perceived risk of reproductiverelated problems and cancers was much lower pertaining to the perception of quitting higher intention to quit was seen if the subjects developed lung cancer heart disease and stroke with slightly less in blindness and distractor variable melanoma while in our study the population placed blindness as the fourth most intention reason to quit smoking in a study done by handa et al 13 patients placed blindness as the second most motivating factor to quit smoking whereas lung cancer was the chief motivating factor on the other hand bidwell et al 14 reported that half of the smokers stated that they would definitely or probably quit smoking if they develop early signs of blindness followed by lung cancer heart disease and stroke this corroborates the study conducted by moradi et al 15 who found out that fear of blindness may be more likely to motivate teenagers to stop smoking than fear of lung or heart disease with approximately 90 of teenagers would cease smoking if there was an early sign of blindness higher than lung or heart diseases smoke cessation is not an easy task among smokers handa et al 13 emphasized that smokers may be more inspired to quit smoking if they were permitted to do it slowly over some time rather than straight away consistent awareness about the hazardous effect of excessive smoking is necessary to avoid complications such as blindness lung cancer stroke disability and worst premature death conclusions the study demonstrates that young adults have limited knowledge of the effects of smoking on their vision awareness of the effects of smoking on lung cancer heart disease stroke and even melanoma received higher ratings than blindness in comparison to other conditions young adults exhibited a lesser fear of blindness and a lower perception of quitting if they thought they would become blind smokers may be able to quit smoking and enhance their quality of life by better understanding the link between smoking and blindness healthcare workers the media and official authorities all have a role to play in informing and educating people about the risks of smokingrelated blindness tissue conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices info all authors have declared that no financial support was received from any organization for the submitted work financial relationships all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work other relationships all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work additional information disclosures human subjects consent was obtained or waived by all participants in this study institutional research board and the ethics committee of king faisal university in alahsa issued approval kfurec2021decea000259 animal subjects all authors have confirmed that this study did not involve animal subjects or

globally it is known that smoking can cause a variety of diseases studies have shown that smoking not only causes heart and lung diseases but is also strongly related to ocular diseases which could lead to blindness this study aims to assess the level of awareness of blindness related to smoking in young people in saudi arabia this is a descriptive crosssectional study conducted among the young population in saudi arabia a selfadministered questionnaire was distributed using an online platform that includes sociodemographic data education level smoking status and knowledge of the harmful effect of smoking like lung and cardiac diseases including blindness the data were analyzed using statistical packages for social sciences spss version 26 ibm corp armonk ny a total of 655 young individuals responded to the survey among our subjects the prevalence of smoking participants was 187 more common among the age group 2125 years males bachelor or higher degrees and those living in the central region p 0001 participants were definitely or probably more aware that the most common condition associated with excessive smoking was lung cancer 995 followed by heart disease 981 and stroke 93 while the least of them was melanoma 913 and blindness 81 this is the first study in saudi arabia to assess the level of awareness of the risks of blindness related to smoking in young people and disclosed limited knowledge of the effect of smoking on their vision the effects of smoking on lung cancer heart disease stroke and even melanoma received higher ratings than blindness smokers may be able to quit smoking and enhance their quality of life by better understanding the link between smoking and blindness which suggests that appropriate action is required to enhance their awareness

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introduction construction safety in china has become a primary concern for people due to the tremendous losses caused by workrelated injuries of personnel 12 the national bureau of statistics of china reported 521 injuries for every 100 workers and 1431 fatalities for every 100000 workers in mainland chinas construction industry in 2018 3 similarly high fatality rate of construction workers was observed in hong kong which is the special administrative region of china for example 317 injuries were reported for every 100 workers and 1251 fatalities were observed per 100000 workers in 2018 4 these statistics highlight the urgent need for all personnel and academics concerned with occupational health and safety in both mainland china and hong kong to reduce the number of accidents to address this issue scholars have considered safety citizenship behavior and safety consciousness as noteworthy topics for investigation of personnel safety 5 6 7 as defined sc is considered a kind of mental perception and understanding of environmental safety and working circumstance of individuals which is highly related to the improvement of behavioral safety levels and humanity living environments 8 scb can be interpreted as a voluntary behavior focusing on improving the organizational safety performance and mutual support at group level among employees 9 which is usually shown as mutual voluntary assistance among working members to achieve safety improvement 5 meng et al further expanded the research of sc and scb theories by developing the scale measurements 10 however the research gap regarding the missing comparison of sc and scb between two regions hindered the implementation of safety interventions related to sc and scb that target specific groups of construction workers in these two regions considering the regional background the subtle administrative relationship and similar developing stages of societies and economies were observed with regard to the political and cultural aspects hong kong as one of the special administrative regions of china identifies traditional chinese culture within an abstract and detached sense while its administrative mode is distinguished with a typical communist regime in mainland china for the social development aspect the hong kong government has maintained a capitalist system and it has incorporated local and overseas elites into administration and political consultations because of its colonial background which previously situated hong kong at a leading position the regional similarity and difference may further lead to influential distinction of occupational safety of the construction personnel under the specific circumstance 7 however the seriousness of fatal accidents in the construction industry was still reported in both regions with no research comparing or discovering the possible reasons in terms of specific characteristics of the construction personnel to fill such gap this paper aims to identify and compare the difference in sc and scb between mainland china and hong kong including the influence of demographic factors such as gender education level age and weekly working hours since the previous studies have demonstrated the remarkable influence of personal characteristics on personnel safety 81112 this paper provides a starting point for further research on the comparative study of demographic influences on the personnel safety of construction workers between regions it then analyzes the reasons for and the resultant implications of the territorial differences which can help these regions learn complementarily from one another materials and methods theories of sc and scb sc refers to the positive individual attitude and perception of environmental safety and working circumstances 13 the safety behavior of humans and their living environment can be enhanced by promoting safety consciousness 67 scb is an organizationbased voluntary behavior that focuses on improvement of mutual support and safety performance at the organizational level 9 compared with traditional safety behavior which focuses on the individual acts for ensuring personal safety scb is considered preferable for safety research because it is more related to the overall safety of the organization 5 meng et al developed scales to measure sc and scb for the construction industry which were also applied in the present study due to the considerable reliability and validity 10 comparing the safety constructs between these two regions is deemed feasible and valuable given the subtle relationship between mainland china and hong kong specifically hong kong functions within a legal environment with a capitalistic state but still partially adheres to traditional chinese cultural patterns 1415 this study compares the sc and scb between mainland china and hong kong construction workers given that the safety of construction personnel is considered an important issue in both regions with different social and political conditions for the former personal unsafe behavior has been identified as the main cause of the high accident rates in its construction industry 1617 accordingly construction companies in hong kong have extensively implemented preventive measures such as preventionbehaviorbased safety management and supervisorfocused behaviorbased safety methods to improve the safety of their workers 1819 meanwhile the government of mainland china has organized vocational education training to enhance the qualifications of construction workers in both theoretical and practical aspects 20 demographic influence previous studies revealed several potential demographic variables that may cause effect towards an individuals perception personality performance and organization and betweenmember interaction including gender age working hours and education level 21 22 23 24 25 26 27 28 in detail females have been involved in fewer accidents and have a higher riskavoiding consciousness than males 29 nevertheless some discussions persist about regional ambiguity as female workers sometimes suffer higher risk due to higher job stress and injury rate than male workers 30 education has been considered a direct and effective strategy for improving work capability and safety skills 31 but some uncertainties regarding the regional influence of education level on the personal awareness and organizational safety of construction workers remain unaddressed due to the observed insignificant correlations 32 for age schwatka and rosecrance indicated that young workers will have better safety at work compared with older workers because of their better alertness to potential threats and higher physical capacities 33 however some studies have reported the opposite conclusion regarding the regional age effect on safety of workers due to the finding of preferable personnel safety of elder workers with better safety experience 3435 moreover lee and lee pointed out the possibility of workinghour reduction to save workers from unsafe situations 36 skogstad et al found that unreasonable working hours strongly increase the likelihood of increased occupational injuries and illnesses 37 which will also cause improper work shift that causes disorders in workers lives and leads to health problems 3839 from the above although the previous studies have proven that demographic factors significantly influence the safety of personnel the effect will be influenced as the change of certain circumstances sometimes even convert the demographic influence from positive to negative 4041 therefore to fill this research gap the present study aims to conduct a crossregional comparison between hong kong and mainland china for the influence of demographic impact on sc and scb which are representative of the personnel safety of construction workers hypotheses table 1 lists 17 hypotheses to clarify the crossregional differences in the demographic effects on sc and scb the sc and scb of hong kong workers were assumed to be higher than that of mainland workers due to the higher level of education and technology acceptance during the rapid city development in recent years 42 the trend of demographic influence in hong kong was hypothesized to be identical with mainland china due to their similar cultural background of east asia 15 moreover the regional comparison of the intensity of the demographic effect was included in the hypotheses no content h1 hong kong construction workers perform higher sc and scb than mainland construction workers h2 gender difference causes significant influence on the sc and scb of construction workers in two regions h2 a crosssectional survey was conducted on site with the assistance of local worker unions and companies from september 1st 2021 to april 30th 2022 by which the demographic information and sc and scb data of the workers were collected a total of 530 respondents were recruited from relevant construction enterprises to fill out the questionnaire and 509 valid data were finally obtained the questionnaire adopted in this study was previously developed and published by meng et al 10 for measuring the correlation between sc and scb and is now widely applied in relevant studies due to its considerable reliability and validity 4344 the present study further expanded the research to the cross regional comparison between hong kong and mainland china about the demographic influence on sc and scb of construction workers the questionnaire was translated into mandarin and cantonese and some descriptions of the items were revised in line with the linguistic customs and local background of mainland and hong kong workers respectively the questionnaire included 11 sc items and 12 scb items which were divided into four parts in line with the dimensions of sc and scb the sc dimensions involved conscientiousness familiarity with safety regulations dependency of work experience and education on safety skills while the scb dimensions included selfcontrol relationship between superiors and subordinates mutual aid and participation in suggestion making all items were rated on a fivepoint likert scale ranging from 1 to 5 before answering the questions the respondents were asked for their demographic information including their education level age gender and weekly working hours for research ethics all respondents granted their informed consent by signing their names before answering the questionnaire all participants provided written informed consent before participating in this study and agreed to the terms and conditions this study did not require the participants to be involved in any physical andor mental intervention participants information was anonymized and deidentified prior to analysis this research did not obtain identifiable private information this research gained the approval of the ethics subcommittee of research committee in city university of hong kong and china national institute of standardization data analysis the collected data were assessed for their reliability and validity to test the effectiveness of the scales the internal consistency reliability was evaluated to test the consistency of multiple items for measuring the same construct 45 composite reliability was tested for each dimension to measure the reliability degree of compositional constructs 46 convergent validity was assessed by using composite reliability together with factor loading and average variance extracted 47 discriminant validity was evaluated by comparing the square root of ave with its largest interconstruct correlations for a certain factor 48 confirmatory factor analysis was performed to evaluate the degree of fit of the measurement model to the research data goodnessoffit indices as well as root mean square residual tuckerlewis index root mean square error of approximation chisquare divided by degree of freedom and comparative fit index were used to determine whether the cfa model has a good fit to the data 49 after the reliability and validity tests descriptive analysis was conducted to present demographic distributions of the accumulated frequencies of reported sc and scb scores for hong kong and mainland china and further compared for the significance of the between group differences through the analysis of variance in terms of different demographic information 50 moreover multinomial regression was used to predict the possible outcomes of sc and scb with different categorizations of demographic information 51 structural equation modeling was applied to quantitatively measure the influence mechanism of demographic factors in two regions all the demographic variables were coded according to their categories table 2 presents the detailed coding system for the demographic variables age gender education level weekly working hours 20 1 male0 junior middle school or below1 35 1 2030 2 female1 high school2 3540 2 3140 3 technical school3 4145 3 4150 4 undergraduate or above4 4650 4 50 5 5155 5 55 6 results validity and reliability test the internal consistency reliability of the scale was tested by using cronbachs alpha and table 3 presents the results the cronbachs alphas of sc and scb for both hong kong and mainland china exceeded 07 thereby indicating the high level of internal consistent reliability of the data 45 table 3 shows the good acceptances of the factor loadings of all items for both regions table 4 shows that the composite reliabilities of sc and scb for both regions exceeded 07 while the values of ave were all larger than 05 48 good convergent validity was therefore verified as reflected in the acceptability of composite reliabilities values of ave and factor loadings 475253 tables 5 and6 indicate that the largest pearson correlation between different dimensions of sc and scb is lower than the square root of ave for each dimension the discriminant validity of each dimension of sc and scb was therefore verified 54 as depicted in table 7 the cfa model of hong kong was tested using the following criteria χ2df 3292 tli 0954 cfi 0969 rmsea 0021 gfi 0921 and rmr 0049 which altogether demonstrated a remarkable degree of fit of the measurement model to the questionnaire data for mainland china a high degree of fit was also verified between the data and the model 49 descriptive analysis table 8 shows the demographic distributions of the accumulated frequencies of reported sc and scb scores for both mainland china and hong kong the highest proportion of respondents was observed to be 3140 years old for two regions most of the respondents had high school diplomas and worked 41 to 45 h per week overall male construction workers had higher sc and scb scores than their female counterparts hong kong construction workers showed higher sc and scb scores than their mainland counterparts the average scores of every item for sc and scb were presented on a butterfly graph each questionnaire item was set as the axis and the average score of each item was represented as shown in figure 1 the hong kong respondents only had two items lower than those of mainland counterparts the average scores of every item for sc and scb were presented on a butterfly graph each questionnaire item was set as the axis and the average score of each item was represented as shown in figure 1 the hong kong respondents only had two items lower than those of mainland counterparts working anova for the comparison of the demographic differences in sc and scb between hong kong and mainland china tables 9 and 10 depict the results of anova to evaluate the significances of distinctions table 9 reveals significant differences in the sc and scb of construction workers between regions as shown in section 41 the sc and scb of hong kong workers were significantly higher than those of mainland workers table 10 reveals that all demographic variables significantly differentiate the sc and scb of construction workers in hong kong and mainland china given that the values of p were all less than 0001 combined with the statistical analysis presented in section 41 the sc and scb of male workers were significantly higher than those of female workers in two regions sc and scb of workers with higher education level were significantly higher than those with lower education level in both regions workers with longer working hours reported significantly lower sc and scb in two regions older construction workers had significantly higher sc and scb than younger workers in mainland china whereas the sc and scb decreased along with increasing age in hong kong demographic influence modeling to compare the influence mechanism of demographic variables on the sc and scb of construction workers in hong kong and mainland china quantitatively structural equation modeling was performed to estimate the impact of different demographic variables on sc and scb as shown in figures 2 and3 table 13 depicts that both sc and scb models exhibited good fit to the data as is vividly shown in the figures the negative effects in the mainland china model were verified in line with the coefficients of gender and weekly working hours meanwhile age and education level showed positive effects on sc and scb for hong kong only el showed a positive effect on sc and scb whereas gender age and wh showed negative effects to both safety constructs according to their coefficients in order to compare the demographic influence on sc and scb between hong kong and mainland china test of invariance routine was conducted to identify performing distinction of the research model between regions 55 the differences of goodnessoffit indices were examined and listed in table 14 which reveals significant distinction of sem between two regions in terms of demographic influence on sc and scb 55 in order to compare the demographic influence on sc and scb between hong kong and mainland china test of invariance routine was conducted to identify performing distinction of the research model between regions 55 the differences of goodnessoffit indices were examined and listed in table 14 which reveals significant distinction of sem between two regions in terms of demographic influence on sc and scb 55 in order to compare the demographic influence on sc and scb between hong kong and mainland china test of invariance routine was conducted to identify performing distinction of the research model between regions 55 the differences of goodnessoffit indices were examined and listed in table 14 which reveals significant distinction of sem between two regions in terms of demographic influence on sc and scb 55 furthermore the significances of different influence paths were verified as shown in table 15 in which all paths were significant given that the p values were all less than 005 though the strength of the demographic effect was partially different between two regions specifically a stronger effect of gender was shown in mainland china while the stronger influences of workhour and age were found in hong kong therefore h1 was verified because the sc and scb of mainland workers were lower than those of hong kong workers h2 h21 and h23 were all accepted since the significant negative influence of gender was greater in mainland china compared with that in hong kong which further led to the rejection of h22 h3 and h31 were supported but h32 and h33 were rejected given the positive effect of education on sc and scb in two regions which were all significant at 0005 level h4 was accepted due to the significance of age effect but h41 h42 and h43 were all rejected given the negative effect of age in hong kong and positive effect in mainland china h5 h51 and h52 were supported given the stronger negative effects of weekly working hours in hong kong at a 0001 significance level which further led to the rejection of h53 discussion regional similarity 411 territorial education strategies workers with insufficient education have a limited understanding of safety and working capabilities 56 male and female workers in both regions with higher education were reported to have higher sc and scb scores the influence of education on sc and scb were significant at a 0005 level in both hong kong and mainland china which validated the effectiveness of education in enhancing the sc and scb of workers generally the education level of mainland workers is lower than hong kong workers because more of the latter obtained high school degree and more of the former only obtained junior middle school degree or below the relevant mainland authorities should be concerned that the lower education level of the workers will create a huge obstacle toward the understanding of the safety education because of the shortages of general knowledge and learning capacities 57 therefore using graphical presentation and example illustration is recommended in areas that are difficult to understand while conducting onjob campaigns and safety courses preferably with rewards and incentives for workers to ensure the learning initiative such as safety performance reward or paid learning time 58 however in this study hong kong respondents reported lower scores in terms of the safety regulation of construction industry than their mainland counterparts therefore workers education in hong kong should be more emphasized on the learning of the construction regulation to facilitate their proper understanding and familiarity to the common ordinance and laws of hong kong construction industry such as fire safety ordinance cap 572 and building ordinance cap 123 workhour design workhour was identified in both regions as a significant predictor of occupational injuries with more workload corresponding to lower sc and scb one possible explanation for such finding is that a prolonged working time will exhaust workers and reduce their concentration and consciousness thereby negatively affecting their attitudes and organizational participations toward work safety 3659 to solve this problem working duration should be properly scheduled to optimize the working efficiency and safety performance of construction workers 10 rest intervals should be integrated to guarantee the recovery of workers physical strength additionally adverse weather conditions should be considered in the design of workhours as a stressor of workload 60 to illustrate outdoor works such as masonry and earth excavation starting from 12 pm during midsummer should be suspended and delayed until 3 pm due to the physical consumption and work burnout caused by high temperature regional differentia 421 individual and organizational motivation sc of the respondents from hong kong is higher than that of the respondents from mainland china which may be attributed to the carrying out of safety incentive systems and high levels of professional education in the hong kong construction industry the hong kong government has introduced a pay for safety scheme project where contractors planning to tender for public infrastructural works can include several safetyrelated tasks as part of their bills of quantities these contractors will be paid for these items when these tasks are successfully implemented and achieved which can increase the conscientiousness and motivation of managers and workers 61 moreover the hong kong occupational safety and health council has organized training courses since 1988 for construction personnel who aimed to promote site safety 62 therefore the construction management of mainland china is suggested to take hong kong as an example by conducting safety incentive system and site safety education for workers to enhance both conscientiousness and safety knowledge thereby further improving sc 8 construction workers in hong kong were verified to have better scb than their counterparts in mainland china because of the high education level the management and supervisory staff groups in the hong kong are highly educated and concerned about the safety of their coworkers and employees 63 management believe that the poor safety of personnel will negatively affect the reputations of the company and induce high compensation therefore they tend to play a proactive role to guarantee the safety of their workers and protect the interests of their organizations 6465 by contrast the managers of construction companies in mainland china lack authority to make decisions and are not responsible for the profits and losses of the projects therefore they generally lack the motivation to carry out their work with costeffectiveness 6667 the present study recommends that the relevant authorities and management of mainland china conduct a reward mechanism for safety cooperation of construction employees such as remuneration and extra vacation for personnel who make prominent contributions to organizational safety 68 as well as the continuing education of highquality leadership for construction management and group leaders to improve the scb of construction workers by learning from the experience of hong kong 69 ageing problem to compare the difference in different age groups the workers below 20 years old in hong kong performed better sc and scb than those in mainland china which is mainly due to the superior education popularization and quality in hong kong with the age increasing the changing trends of sc and scb were shown to move in the opposite direction the elder workers in mainland china reported higher sc and scb which perceive more support and encouragement from organization and are more willing to wear the safety equipment than their younger counterparts 70 these elder workers also realize that few job opportunities are available to them thereby driving them to show higher commitment to their work and more willingness to obey safety regulations of the supervisor 7172 by contrast the negative relationship of age with sc and scb in the construction industry of hong kong was clarified which is mostly attributed to the declining trajectories of the working ability and retirement pathways of the hong kong workers 73 specifically peng and chan considered reduced working capacity and psychological engagement as the obstacles to personnel safety among the elder workers in hong kong 74 they further attributed the reduced risk perception and avoidance of hong kong elder workers to the changes in the trajectories of working ability along with age 75 which negatively affect the conscientiousness of risk avoidance and working cooperation 7677 the study further analyzed the slope coefficients of ageing effect in two regions which revealed the influential strength of ageing in different periods of time as shown in table 16 the effect of ageing was proven to be stronger on sc and scb between groups with age codes 1 and 2 the effect continued to decline before the age of 4550 after which the impact of ageing was recovered to be predominate after the individual is more than 50 years old the findings can be corroborated by the nonlinear development and senility of personnels body function and psychological cognition 78 safety cooperation of construction employees such as remuneration and extra vacation for personnel who make prominent contributions to organizational safety 68 as well as the continuing education of highquality leadership for construction management and group leaders to improve the scb of construction workers by learning from the experience of hong kong 69 ageing problem to compare the difference in different age groups the workers below 20 years old in hong kong performed better sc and scb than those in mainland china which is mainly due to the superior education popularization and quality in hong kong with the age increasing the changing trends of sc and scb were shown to move in the opposite direction the elder workers in mainland china reported higher sc and scb which perceive more support and encouragement from organization and are more willing to wear the safety equipment than their younger counterparts 70 these elder workers also realize that few job opportunities are available to them thereby driving them to show higher commitment to their work and more willingness to obey safety regulations of the supervisor 7172 by contrast the negative relationship of age with sc and scb in the construction industry of hong kong was clarified which is mostly attributed to the declining trajectories of the working ability and retirement pathways of the hong kong workers 73 specifically peng and chan considered reduced working capacity and psychological engagement as the obstacles to personnel safety among the elder workers in hong kong 74 they further attributed the reduced risk perception and avoidance of hong kong elder workers to the changes in the trajectories of working ability along with age 75 which negatively affect the conscientiousness of risk avoidance and working cooperation 7677 the study further analyzed the slope coefficients of ageing effect in two regions which revealed the influential strength of ageing in different periods of time as shown in table 16 the effect of ageing was proven to be stronger on sc and scb between groups with age codes 1 and 2 the effect continued to decline before the age of 4550 after which the impact of ageing was recovered to be predominate after the individual is more than 50 years old the findings can be corroborated by the nonlinear development and senility of personnels body function and psychological cognition 78 for age codes 201 20302 31403 41504 505 in addition the findings reveal that additional workhours will cause a stronger negative effect on sc and scb of hong kong workers than mainland workers which is mainly due to the large proportion of ageing workforce of the hong kong construction industry with insufficient physical and psychological strength to achieve consciousness safety cooperation of construction employees such as remuneration and extra vacation for personnel who make prominent contributions to organizational safety 68 as well as the continuing education of highquality leadership for construction management and group leaders to improve the scb of construction workers by learning from the experience of hong kong 69 ageing problem to compare the difference in different age groups the workers below 20 years old in hong kong performed better sc and scb than those in mainland china which is mainly due to the superior education popularization and quality in hong kong with the age increasing the changing trends of sc and scb were shown to move in the opposite direction the elder workers in mainland china reported higher sc and scb which perceive more support and encouragement from organization and are more willing to wear the safety equipment than their younger counterparts 70 these elder workers also realize that few job opportunities are available to them thereby driving them to show higher commitment to their work and more willingness to obey safety regulations of the supervisor 7172 by contrast the negative relationship of age with sc and scb in the construction industry of hong kong was clarified which is mostly attributed to the declining trajectories of the working ability and retirement pathways of the hong kong workers 73 specifically peng and chan considered reduced working capacity and psychological engagement as the obstacles to personnel safety among the elder workers in hong kong 74 they further attributed the reduced risk perception and avoidance of hong kong elder workers to the changes in the trajectories of working ability along with age 75 which negatively affect the conscientiousness of risk avoidance and working cooperation 7677 the study further analyzed the slope coefficients of ageing effect in two regions which revealed the influential strength of ageing in different periods of time as shown in table 16 the effect of ageing was proven to be stronger on sc and scb between groups with age codes 1 and 2 the effect continued to decline before the age of 4550 after which the impact of ageing was recovered to be predominate after the individual is more than 50 years old the findings can be corroborated by the nonlinear development and senility of personnels body function and psychological cognition 78 codes 201 20302 31403 41504 505 in addition the findings reveal that additional workhours will cause a stronger negative effect on sc and scb of hong kong workers than mainland workers which is mainly due to the large proportion of ageing workforce of the hong kong construction industry with insufficient physical and psychological strength to achieve consciousness safety cooperation of construction employees such as remunerat for personnel who make prominent contributions to organizationa the continuing education of highquality leadership for construc group leaders to improve the scb of construction workers by learni of hong kong 69 ageing problem to compare the difference in different age groups the worker hong kong performed better sc and scb than those in mainland c due to the superior education popularization and quality in hon increasing the changing trends of sc and scb were shown to mov tion the elder workers in mainland china reported higher sc an more support and encouragement from organization and are mo safety equipment than their younger counterparts 70 these elde that few job opportunities are available to them thereby driving commitment to their work and more willingness to obey safety re visor 7172 by contrast the negative relationship of age with s struction industry of hong kong was clarified which is mostly attr trajectories of the working ability and retirement pathways of th 73 specifically peng and chan considered reduced working capa engagement as the obstacles to personnel safety among the elder w 74 they further attributed the reduced risk perception and avo elder workers to the changes in the trajectories of working abilit which negatively affect the conscientiousness of risk avoidance and 7677 the study further analyzed the slope coefficients absolute va two regions which revealed the influential strength positive or different periods of time as shown in table 16 the effect of age stronger on sc and scb between groups with age codes 1 and 2 t decline before the age of 4550 after which the impact of ageing w dominate after the individual is more than 50 years old the findin by the nonlinear development and senility of personnels body fu ical cognition 78 codes 201 20302 31403 41504 50 in addition the findings reveal that additional workhours wil ative effect on sc and scb of hong kong workers than mainla mainly due to the large proportion of ageing workforce of the ho industry with insufficient physical and psychological strength to ageing problem to compare the difference in different hong kong performed better sc and scb due to the superior education populariza increasing the changing trends of sc and s tion the elder workers in mainland chin more support and encouragement from o safety equipment than their younger coun that few job opportunities are available t commitment to their work and more willi visor 7172 by contrast the negative rel struction industry of hong kong was clarif trajectories of the working ability and ret 73 specifically peng and chan considere engagement as the obstacles to personnel 74 they further attributed the reduced elder workers to the changes in the trajec which negatively affect the conscientiousn 7677 the study further analyzed the slope two regions which revealed the influenti different periods of time as shown in ta stronger on sc and scb between groups w decline before the age of 4550 after which dominate after the individual is more than by the nonlinear development and senilit ical cognition 78 note for age codes 201 20302 31403 41504 505 in addition the findings reveal that additional workhours will cause a stronger negative effect on sc and scb of hong kong workers than mainland workers which is mainly due to the large proportion of ageing workforce of the hong kong construction industry with insufficient physical and psychological strength to achieve consciousness concentrating and provide altruistic assistance under the excessive workload 279 therefore the relevant authorities and managements of the hong kong construction companies are advised to improve the physical capacity of elder workers by organizing transtheoretical modelbased educational programs involving different activities such as lectures training workshops group discussions and propaganda regarding regular physical activity 80 moreover concerned authorities could hold safety promotional campaigns to increase the mental health of elder workers preferably involving control interventions job stress prevention helpseeking promotion mental health literacy improvement and the establishment of positive leadership practices 81 female caring the sc and scb of female workers are generally lower than their male counterparts female workers in mainland china performed worse sc and scb under a stronger gender effect than their hong kong counterparts which mainly attributed the poor sc and scb of mainland female workers of their working marginalization due to the hegemonic masculinity of males which is specifically generated from the traditional culture in mainland china and not predominant in hong kong due to the difference of regional culture and social background 82 therefore the intensity of gender effect in hong kong is relatively moderate the work schedule and condition should be specially designed for female workers with the consideration of ensuring their occupational health especially for mainland china 83 the heavy jobs such as manual handling and reinforcing works should be reduced for female workers due to their low physical capacity and additional rest interval should be properly scheduled 84 furthermore the perception of organizational affiliation should be promoted for female workers by increasing the support and commitment from all levels of supervision and management through practical measures such as the given voice to value approach so as to help them achieve high cohesion and unity with group members 85 conclusions theoretical and practical contributions this study provides insights into the comparison of demographic influence on sc and scb of construction workers between hong kong and mainland china as one of its important theoretical contributions this study firstly recommends a specific focus on the territorial comparison of sc and scb to design targeted and effective measures and suggestions for sc and scb improvement specifically the gender and workhour caused negative effect towards sc and scb in both regions while the effect of education was positive sc and scb of hong kong workers were higher than those of mainland workers although the influence of age was shown to be negative in hong kong the positive impact of age was verified in mainland china the insights generated by this study offer construction management practical implications the findings put forward a territorial plan of safety education for construction workers in hong kong and mainland china respectively moreover the optimized workload and work conditions are discussed with consideration of environmental and gender characteristics in both regions in addition the construction management is recommended to carry out safety incentive and reward mechanisms in mainland china for cooperation and contribution of construction employees while the hong kong construction companies should improve the work safety of elder workers by organizing transtheoretical modelbased educational programs data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to privacy and ethical considerations multinomial regression tables 11 and 12 present the multinomial regression results for sc and scb of construction workers in mainland china and hong kong respectively all coefficients of the demographic variables were verified as significant in these two regions given that the values of p were all less than 0001 no multiple collinearity was observed among the different factors in accordance with the acceptable tolerance and variance inflation factor the regression constants refer to the intercept of the function for hong kong the regression constants for sc and scb were 3525 and 4588 respectively indicating greater intercepts compared with those of mainland china the values of adjusted r 2 represent the degrees of explanation of the variables toward the variations of sc and scb limitations this research still has certain limitations first the scope of demographic information can be further expanded and the length of working service can be added as additional demographic information to enhance the effectiveness of the research second the data obtained from the survey were crosssectional and the tested effects of demographic variables only focused on a static time point instead of the overall process which may partially eliminate the interpretation of the influence mechanism toward sc and scb future research is suggested to improve the data collection process by distributing and collecting data over multiple periods of time

the construction industry has rapidly developed with continuous prosperity in hong kong and mainland china although accidents still occur with unacceptable frequency and severity for promoting the safety issue of workers in construction industry safety citizenship behavior scb and safety consciousness sc were considered two influential constructs and further studied with integration of sociodemographic theories by scholars however no study has compared the sc and scb of construction workers in terms of the demographic influence between mainland china and hong kong to fill this research gap this study investigated the territorial difference between these two regions by conducting a crosssectional questionnaire survey with recruitment of 253 mainland construction workers and 256 hong kong construction workers significant similarities and differences of sc and scb performance were revealed in terms of the workers with different genders education levels weekly working hours and ages this study provides insights into the comparison of demographic influence on sc and scb of construction workers between hong kong and mainland china which is unique as it can yield useful managerial knowledge relevant to the personal safety of targeted groups of construction workers with particular demographic characteristics in both regions and contribute the implementation of safety interventions in line with the specific distinction in the territorial aspect

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background endoflife communication is a wellresearched phenomenon amongst terminally ill patients often in liaison with healthcare professionals 12 studies show that communication becomes increasingly difficult in terminal cancer which inevitably entails conversations around dying and death 3 4 5 the cited studies illustrate that deterrents to such communication include fear of stirring up emotional distress attempts at mutual protection by patients family members and health professionals and the quest to keep hope alive through engaging in positive conversations in addition preexisting patterns of family communication prior to the onset of illness which avoid difficult or distressing subjects are also likely to deter frank discussion at this stage 67 an implicit assumption in much of the palliative care literature is that palliative care takes place in the context of a reasonably well resourced health system where there are sufficient resources to cater for the needs of patients along the various trajectories of illness a contrasting scenario is evident in palliative care in subsaharan africa characterized by under resourced healthcare systems in this context predominant palliative care models include hospital care community homebased care and integrated community and homebased care 8 both models initially established as a response to the hiv aids pandemic target service provision in areas with limited access to public healthcare facilities many of which are in rural towns 8 9 10 consequently some urban dwellers may not have access to these services alternative models of palliative care in urban africa include homebased care with supplementary services of paid nursing care funded either privately by families or through medical aid organizations as well as inpatient care in nursing homes frail care facilities hospices and hospitals as illustrated in two south african based studies 1112 access to alternative palliative care is associated with affluence which determines who can afford to pay for such services andor who has access to health insurance that can cater for these services in kenya where the current study is based the concentration of specialized cancer management services and oncologists in nairobi 1314 has led to movement of cancer patients from rural areas to nairobi to seek specialized services most of which are palliative in nature this bears implications for endoflife care which is often delegated to family members and relatives residing in nairobi as illustrated in this article caring for patients with incurable cancer often occurs at home with a family member taking primary responsibility for care and hospitalization when patients are deemed too ill for informal home care in addition to being a hub of cancer care cosmopolitan nairobi is significant as a melting pot of cultures this shapes endoflife discourses as terminally ill patients and their families simultaneously straddle cultural community beliefs and more contemporary beliefs about illness and dying against this background there is a need to better understand the experiences of families of terminally ill cancer patients in an urban context with a view to contributing to research on culturally relevant endoflife care 15 this article seeks to contribute to this need by examining the content and contexts of family endoflife conversations and decisions based on the retrospective accounts of a sample of bereaved women family cancer caregivers in nairobi the following questions are addressed what was the nature of family interactions who initiated endoflife discussions how did family members caregivers and cancer patients respond to such conversations which cultural discourses featured in these conversations this paper is developed from a broader study which explored the lived experiences of family cancer caregivers in nairobi 16 method procedure ethics clearance to conduct the doctoral study from which this article is developed was obtained from university of cape town research ethics committee department of psychology 16 this ethics approval granted clearance to approach various gatekeepers for assistance in sourcing participants at the time no further ethics approval from kenya was required as this was prior to the establishment of kenyas national commission for science technology and innovation act 28 of 2013 which as of 2014 currently requires all persons conducting research in kenya to obtain a research permit in addition to institutional ethics approval the study did not include cancer patients and thus no approval from the medical health departments in south africa or kenya was required participation was voluntary during initial consultations with potential participants jng discussed the nature of the study and gave opportunity for questions and clarifications this entailed clarifying that study findings would be utilized for academic research purposes and that participants identities would be safeguarded in the process prior to the start of a focus group discussion each participant gave written informed consent including permission to audio record the focus group discussion further each group member gave verbal consent for a research assistant to sit in and take down observational notes focus groups were conducted by jng with the aid of two research assistants one who assisted with logistics of setting up for focus groups and another who wrote down observational notes during focus groups the focus groups venues all of which were in nairobi and easily accessible to all participants were determined in consultation with participants in order to allow both for individual views and for issues to be discussed and coconstructed four mini focus group discussions 2021 were held a detailed explanation of the rationale for the use of these focus groups is furnished in a methodological article 22 the small group format was especially appropriate to this context in many african contexts issues of health and care are negotiated and discussed in community discursive contexts in addition a number of participants requested to be interviewed in small group format the first focus group lasted over 3 h with participants deeply engaged in conversations about their experiences the researcher thus decided to reduce the group sizes of subsequent focus groups to give ample time for sharing of individual narratives as well as group conversations around these accounts the average time for each subsequent focus group was 2 h discussions were held in english data analysis the study utilized an interpretative phenomenological analysis approach which focuses on indepth investigation of peoples significant life experiences meanings ascribed to such experiences and further how individuals make sense of these experiences 23 ipa procedures for data analysis 24 which are adaptable for focus group data analysis served as guidelines 2526 data analysis in which focus groups were analysed consecutively involved several readings of each focus group transcripts while writing down observations and comments on a margin alongside the numbered meaning units in each transcript 24 the interpretation process entailed a moving back and forth between individuals subjective experiences as well as shared aspects of experiences collaboratively negotiated in the course of focus group exchanges 2526 in addition hermeneutic process involved realtime sensemaking taking into account the chronological order in which participants narrated their experiences and the deconstruction of events and organization of these into thematic ideas that is posthoc meaning making 26 emergent themes based on experiential claims were listed and further clustered into broader themes following analysis of each focus group a thematic analysis across the 4 groups foregrounding points of convergence and divergence was undertaken the following section explores two endoflife themes that arose in fgds results in this section we present some findings from the four fgds fgd 1 comprised 5 women aged 3452 years all professionals working nairobi who had cared for a family member with terminal cancer fgd 2 comprised 3 elderly widows each of whom cared for a spouse with terminal cancer fgd 3 comprised 3 women aged 3136 years who each cared for a terminally ill parent while fgd 4 consisted of 2 women aged 27 and 33 years who served as caregivers of siblings with terminal cancer utilizing relevant illustrations from fgds this section discusses the content and contexts of family endoflife conversations and meanings ascribed to these conversations two related themes are presented advance directives as preparedness for death and initiating death talk these themes were developed from jngs dissertation chapter on death dying and bereavement transitions in the context of family caregivers experiences of midwifing death 27 watching and waiting on their terminally ill loved ones as death approached we utilize the term advance directives in the broader sense of and verbal or written instructions conveying a persons health care preference while they are competent to make decisions for themselves… in our specific context advance directives include wills donotresuscitate directives and other variations of endoflife conversations and decisions regarding terminally ill cancer patients and from the perspectives of lay family caregivers the symbol indicates omitted sections of text pseudonyms are utilized to safeguard participants identities advance directives as preparedness for death its not that im dying right now the theme of wills generated substantial discussion among focus group participants wills were considered a hallmark for preparedness or lack of preparedness for death as illustrated in the following excerpts drawn from an fgd 1 conversation the statement its not that im dying now points to the commonly held kenyan belief that speaking about death implies summoning it which might explain elimus husbands need to reassure his family that he was not on his death bed at the time of issuing his will retrospectively elimu appreciated her husbands advance directives in aiding her cope with his death elimu elimus experience seems to have caused other group members to recall and reflect on their own experiences with elimus story as the point of reference for baraka and usafis meaningmaking moderator i dont know if anyone has something to say as we part what would you say to other women who are going through this as we end our discussion baraka well the only thing id say im very happy that your elimus husband did that because my mother didnt do that and it left us in disarray i think thats very helpful because reality is reality whether you like it or not and i kept on telling my sisters this and actually they thought i was an enemy at one point they just told me you want your mother to die which is not the case i didnt know the date but from my senses i could tell that this is not the road to jahazi town parents current residence this is the road to mpakani town rural home where the grave was going to be put and this is where i really feel as a family we went wrong and we did not support my mum because we were not giving her strength to to to be dignified just be like this gentleman who died because i think it was a very dignified death baraka sought to initiate endoflife discussions with her sisters in an effort to support her mother by facilitating what she deemed a dignified death this yielded dissonance between cultural beliefs regarding speaking about death being perceived as a death wish versus the reality of impending death communicated in barakas metaphor of the roads symbolizing the common kenyan practice of burial in rural homes in this cultural context a death wish may be interpreted as ill will towards a seriously ill family member in the sense that you want your mother to die in contrast to waiting for the ill person to communicate ones dying wishes like in elimus case however barakas intent seemed to be encouraging death talk in the context of preparation for death a perspective documented in palliative care literature 1229 the context of the cited studiesestablished palliative care facilities with palliative care professionals differs from the current study where endoflife care conversations occurred in home or hospital contexts outside of formal palliative care structures usafi picked up the conversation incorporating both elimu and barakas experiences in her meaning making usafi yes i just wanted to identify with eh auntie elimu for me i think what helped us as a family is being prepared dad has been sick for a long time but it wasnt until last year june that he sat us family down and told us i want you people to walk with us this journey i remember sharing with a friend and im telling her hĩĩ the way this man has shared its like hes going to die the next minute so he wrote his life storyhe actually gave it to us and so we safeguarded the family history he told us where he wants to be buried when i heard you baraka talk i was thinking your mum hid so much she didnt want to see you in pain and sometimes for a woman its harder for a man i think hes feeling like if i leave my family like this everything will be you know in disarray similar to elimus account usafi and her family were invited to play audience as her father gave advance directives for usafi this entailed navigating the tension between the traditional belief that speaking about death is summoning it and respecting her dying fathers wishes to discuss his endoflife concerns with the family usafis last comment supports gendered socialization of men as the heads of patrilineal households with responsibility for decisionmaking in the home 30 and women as carers and nurturers of their children and spouses including caring for ill family members 3132 hence it is understandable how womens concern at the end of life would be to ensure the emotional comfort of their families which might include avoiding death talk to avoid upsetting them this resonates with the sentiments of a sample of south african cervical cancer patients some of whom were concerned about the potential emotional distress to their families upon disclosure of their diagnosis 33 however the following section demonstrates that beyond gender there were other factors in play initiating death talk whose call he wouldnt talk huruma an elderly widow in fgd 2 found herself caught in the tension between her childrens demand for their fathers will and her husbands silence about it huruma i actually remember telling my husband to write a will or to discuss with me what he wants with his with the properties because my son kept on telling me mum you people have to write a will and i kept on talking to my husband silence then lowers voice and his mouth was tightlipped he wouldnt he wouldnt say he wouldnt say a single thing brief silence and in fact i i felt like i was pressurizing him because my children were also telling me talk to him ask him spoken in whispers but emphatic has he got a will but he wouldnt talk silence he would not say a thing jahazi he did not believe in wills huruma no he wouldnt talk at all he wouldnt say and i realized now i am pushing him or i am making him say things he doesnt want to say because he would just keep quiet and look at me in addition to her primary caregiver role huruma was a mediator between her children and husband one could sense her predicament as she was caught between her husbands avoidance the demands of her children and her quest to maintain family harmony jahazis comment he did not believe in wills insinuates that refusal to issue his dying wishes may be linked to known cultural traditions huruma also alluded to the possibility that her husband may have considered being pressured to give his will inappropriate and thus resisted her attempts perhaps silence was his way of protecting his family from distress in light of his impending death as observed among terminally ill parents in an american based study that investigated reasons for avoidance amongst families coping with lung cancer 7 nevertheless hurumas husbands avoidance seems to negate usafis idea of gender role socialization as a determinant of who should issue advance directives in another focus group ojimas 29 year old terminally ill sister was both explicit about her dying wishes and concerned for her familys emotional wellbeing ojima she called my brothers and myself sat us down told us you guys this thing is terminal and you know ill be gone pretty soon so you guys need to start dealing with it have you thought about therapy i understand that the hospice therere people who can help you deal with deal with this i was like too much you know were like why are you saying that my brother was like stop talking stop talking like that she said seth its terminal the sooner you guys get to grips with it the better she told my parents you guys need to release me im ready to go she said all her goodbyes she ran us through her funeral program as she wanted it ojimas sister seemed intent on preparing her family for her death despite their unpreparedness evident in the siblings attempts to stop her from talking like that ojimas sisters recommendation for therapy suggests concern for her familys emotional wellbeing and relational harmony a theme featured in endoflife discourses 34 in certain instances death talk featured directives regarding prolonging of life in terminal cancer in the absence of explicit dying wills caregivers and their families took responsibility for endoflife decisions when their ill loved ones deaths were at hand 34 jahazi and fikira recalled making difficult decisions close to their spouses deaths jahazi we were told that the doctor wants to see the immediate family he tried to explain to us that people may sometimes require that the patient be taken to icu intensive care unit when the heart stops but he said he would perhaps feel that that would be an unwise thing to do because of the bills that would be involved in icu and yet you know it is a terminal illness but he cannot force any decisions on the family and the family would have to decide so we were asked should the heart stop what would you like us to do that was the hardest question and nobody was ready to answer it so we all kept quiet we looked at him until i realized until i said something nobody would so i said well go by his the doctors word and then we went round every member of the family said well do what mum has said that was on monday night he passed away on thursday night rather than summon jahazi given that as the spouse and primary caregiver she would be considered the next of kin he requested to meet the immediate family the final decision was made jointly through family consensus fikiras contrasting experience reiterates the significance of family communal decision making in terminal illness fikira he the doctor called me and said mrs fikira i want you to sign here if your husband deteriorates at night i want you to give us consent that we dont take him to icu if he was my father thats what i would have donehe was a young doctor because he is going to be on a life machine and this doesnt help but just tell me what you want now this is where the decision was very difficult i i signed and after the doctor had gone my daughter cried sobbed mummy how can you do emphasis that i wish he had told me before so that i consult the members of the family she was very bitter how can you do that sign our daddy out in fikiras case the doctor prevailed on her as primary caregiver to act as the sole surrogate decision maker 3435 on her husbands behalf fikiras response to her daughters outburst suggests the bone of contention was that the decision was made singlehandedly without consulting the other family members who may have held different opinions though it is unclear but possible that fikira dealt with the same doctor he involved fikiras family in the next major decision regarding their ailing father fikira he doctor told us tomorrow monday come and see me with members of the family we went on a monday he told us we have done everything and now medically were not doing anything its only nursing care and therere two thingsyou take him home or we take care of him in hospital which one do you choose many people would like to see their person go die at home and even when they go home sometimes they get better so we chose for him to come home on wednesday he came home friday he went he died peacefully the decision regarding this advance directive made in consultation with family members did raise any objections this discussion underscores the significance of cultural sensitivity for example in this context where family consensus was preferable to decision making by one family member 53436 though both fikira and jahazis husbands were admitted in the same private hospital in nairobi jahazi was neither offered the option of taking her husband home nor of being present with him at his death bed jahazi i told the sister nurse i wanted to stay on for the night and i knew they allowed people because there were other patients that were allowed to have a close member of the family with them when they became very sick and she was adamant she refused emphatic maybe she they knew he was going and i felt very emphatic bad because they refused to allow me to and then because they called me at 300am silence to tell me that he had passed on at 100am could i go to the hospital and i said no ill come in the morning i mean i couldnt even drive jahazis sense of disappointment in the healthcare personnel for denying her the opportunity to be present during her husbands death and regret that she was absent at that critical moment is apparent possibly her role as the informal primary caregiver was neither understood nor appreciated in the formal healthcare set up jahazis experience reiterates the sentiments of a sample of informal cancer caregivers who reported feeling invisible and sidelined by healthcare professionals 37 this raises the question of why some families kept their relatives in hospital despite their knowledge that their illness was terminal nine out of 13 patients died in hospital this is consistent with a botswana based study which showed more deaths including cancer deaths occurring in hospitals in urban cities 38 though the botswana study did not elaborate on the reasons for hospital deaths one possible explanation is that being ill prepared coupled with the lack of resources necessary for home based critical palliative care forced families to take their dying loved ones to hospital 1539 this is in contrast to contexts where alternative resources such as home based andor inpatient nursing and hospice care reduced the instances of hospital based deaths 11 discussion this article examined the content and contexts of family endoflife conversations decisions and meanings ascribed to such communication through the lens of family caregivers experiences of midwifing the death of their ill loved ones two themes featured in focus group discussions amongst bereaved family caregivers advance directives as indicators of preparedness for death and who initiates endoflife conversations the study illustrates the role of family dynamics in influencing the nature of such conversations including when it is deemed the appropriate time for these conversations who should or should not initiate these conversations and who should be included in endoflife discussions 339 sometimes endoflife conversations generated misunderstanding amongst patients and family members in home settings when there were conflicts around emotional and psychological readiness for death talk at a more pragmatic level versus cultural beliefs rendering such conversations taboo in healthcare settings where there appeared to be inconsistencies in how healthcare personnel supported families of dying patients the involvement of families underscores the relational nature of endoflife discourses in this context this may differ from cultural contexts at emphasize individual autonomy and agency and where terminally ill patients take lead roles in endoflife decisions with support from palliative care professionals and sometimes family members 1229 findings demonstrate the transitional nature of family caregiver roles whereas in their narratives several participants identified themselves as primary caregivers to their ill loved ones caregiving emerged as a shared role particularly in the terminal phase where endoflife decisions were negotiated at family level being a caregiver entailed straddling traditional beliefs and more pragmatic perspectives about endoflife conversations in the absence of healthcare professionals assisting in homebased care cancer patients caregivers and their families struggled to navigate the unknown endoflife terrain in certain instances caregivers were called upon to act as surrogate decision makers 3439 either as individuals or in liaison with other family members within the formal healthcare system the timing and haste with which such decisions were made placed an additional emotional burden on caregivers like fikira who had to live with her decision not to take her husband into icu despite her daughters outright disagreement with what she deemed signing our daddy out russ and kaufman 35 posit that such endoflife decisions are in reality not a matter of choice but rather one of endorsing the recommendations of healthcare professionals the implication is that though they often feel responsible caregivers are not responsible for the outcomes of such decisions 37 the main limitations of this study are methodological first the small sample size focused on idiographic understanding calls for caution in attempts to generalize the study findings second data were based on retrospective accounts of bereaved family caregivers hence some details may have been forgotten over time even so some of the findings resonate with previously published studies providing a basis for comparative analyses endoflife matters across varied contexts for example a kenyan based study retrospectively examined advance directives of terminally ill patients based on hospital archived records in a private tertiary hospital 28 findings from this study show that 842 of the patients in this study who issued advance directives were cancer patients limitation of care documents and donotresuscitate were the most frequently reported types of advanced directives while only 3 patients had living wills the authors noted that the retrospective nature of their study was a limitation in exploration of various potentially mitigating factors including patients knowledge and attitudes towards advance directives and the influence of patients relatives in decisionmaking around advance directives both of which are addressed in this article in addition focus group interactions illustrate the value group synergy and collaborative meaning making in harnessing information that might have otherwise not been explored 4041 further the findings demonstrate the possibility of simultaneous elucidation of individual experiences interactive coconstructions and the sociocultural contexts of experiences and meaning making processes in ipa research 264243 conclusions this study shows the paradox of the critical role played by the family as the central cultural and affective unit within which knowledge of terminal illness is processed and care for the dying performed 36 p104 versus the ill preparedness of family caregivers in dealing with endoflife issues 1239 findings bear implications for palliative cancer service provision in urban towns such as nairobi which is predominantly informal home based care with occasional hospital based care in critical phases there is need to engage further with the question of equipping family caregivers with basic knowledge of endoflife care in addition there seems to be potential for more liaisons between family caregivers and healthcare professionals involved in endoflife care findings from this study are relevant in informing palliative psychosocial interventions and specifically the endoflife concerns needs and decisions of cancer patients and their families abbreviations fgds focus group discussions icu intensive care unit ipa interpretative phenomenological analysis competing interests the authors declare that they have no competing interests

background endoflife communication becomes increasingly difficult in terminal cancer which inevitably entails conversations around dying and death in resourcelimited areas the context of endoflife communication is usually homebased palliative care comprising mostly women in the family who play critical roles as informal caregivers this article examined the content and contexts of family endoflife conversations and decisions based on the retrospective accounts of a sample of bereaved women family cancer caregivers in nairobi kenya method an interpretative phenomenological analysis approach was utilized to explore pertinent endoflife communication themes four mini focus group interviews with a total of 13 participants n 5 n 3 n 3 n 2 were conducted results two endoflife themes advance directives as preparedness for death and initiating death talk were examined findings a illustrate the role of family dynamics in influencing the nature of endoflife conversations and decisions b demonstrate the transitional nature of family caregiver roles and c underscore the paradox of the critical role played by family members in palliative care versus their ill preparedness in dealing with endoflife issues conclusions findings are relevant in informing palliative psychosocial interventions and specifically the concerns and decisions of cancer patients and their families this prompts further engagement with the question of how to equip family caregivers in resourcelimited contexts for end of life care methodologically these results demonstrate the possibility of simultaneous elucidation of individual experiences interactive coconstructions and the sociocultural contexts of experiences and meaning making processes in ipa research

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introduction indigenous children in canada are at a disproportionately higher risk for overweight and obesity compared to their nonaboriginal canadian counterparts 12 defined as the accumulation of excess body fat obesity is associated with poor health outcomes including compromised immune function mental health disorders type 2 diabetes cardiovascular disease sleep apnea and decreased quality of life 3 4 5 6 7 according to the 20092011 canadian health measures survey approximately onethird of canadian children and youth between 5 and 17 years of age are classified as overweight or obese with indigenous children and youth being twice as likely to be classified as obese in comparison 4 corroborating this pattern the public health agency of canada reports that 20 of first nations children living outside of first nations reserves and 169 of métis children have a bmi ≥ 30 compared to 117 of nonindigenous canadian children 24 while the etiology of obesity is multifactorial and complex a social determinants of health framework provides a starting point for unpacking the distal causes of child obesity as well as identifying targets for prevention and treatment 89 however the health disparities experienced by indigenous peoples highlight the fact that these social determinants are experienced differently by indigenous populations and must be explored alongside more culturally relevant factors several indigenousspecific social determinants of health models have been developed as a result including an ecological model by willows et al 8 that includes causal factors related to households schools communities and the macrosocial context greenwood and de leeuw 9 use a web diagram to demonstrate that there are multiple interrelated relevant social determinants of aboriginal peoples health operating at various socioecological levels one factor noted in these models that has been gaining increased attention in obesity research is the importance of food security for weight status food insecurity is defined as a situation in which availability or access to nutritionally adequate and culturally acceptable food is limited or uncertain 1011 while the relationship between food insecurity and obesity may seem paradoxical research is increasingly linking the two as food insecurity results in a lack of affordable nutritious food choices which then may result in obes ity 12 13 14 15 16 adults and children have distinct experiences of food insecurity as children are more vulnerable to resultant behavioural problems such as decreased school attendance and performance and poorer overall health and nutrition despite parents efforts to minimize food insecuritys impact 131718 a possible relationship between food insecurity and obesity may be especially relevant for indigenous children as indigenous households are three times more likely to experience food insecurity than nonindigenous canadians 1920 the 20072008 canadian community health survey found that 209 of indigenous households were food insecure with 84 experiencing severe food insecurity 20 in comparison 72 of nonindigenous households were food insecure and 25 experienced severe food insecurity 20 much of this discrepancy can be explained by the higher prevalence of sociodemographic risk factors in indigenous households 19 many of which have also found to be related to obesity 21 previous qualitative research with offreserve métis and first nations parents found that food insecurity was perceived by community members to be an important cause of obesity in their communities 22 in those interviews food insecurity was thought to be not only a result of low income but also the high price of fresh food in some locations and a lack of transportation for some the loss of traditional food and knowledge about its preparation was also important leading to poorer diets 22 however the association between food insecurity and obesity in indigenous children has not been quantitatively examined moreover it is important to consider this relationship in the context of other potentially important effects including house hold characteristics schoollevel factors geography and cultural factors in this paper we make use of the 2012 aboriginal peoples survey 23 to examine the association between household food security status and obesity among offreserve first nations and métis children and youth in canada independent of other household school geographic and cultural factors methods data and participants the 2012 aps was a postcensal national survey of the population aged 6 years and older identified in the 2011 national house hold survey 24 and living outside of first nations reserve communities as well as select indigenous communities in the north 2123 this study focussed on first nations and métis children and youth aged 6 to 17 years inuit children and youth were excluded as the geographydriven factors affecting their food security status as well as their unique bmi profiles and body fat distribution require independent investigation 2526 after excluding the inuit population and adults aged 18 years and over the final sample included 6900 individuals questions for children aged 6 to 14 years were answered by the person most knowledgeable about the child generally a parent or guardian youth aged 15 to 17 years were interviewed directly details about the sampling data collection and weighting are available in the aps concepts and methods guide 23 main variables obesity status the dependent variable was weightstatus based on bmi categorization using coles bmi cutoffs 27 bmi was calculated using pmkreported height and weight of children the aps asked how tall is your child without shoes on and how much does your child weigh in order to calculate bmi 28 weight status categories included normal overweight and obese food insecurity the 2012 aps measured household food insecurity over the past 12 months using a series of six statements to which the pmk responded often true sometimes true or never true the statements captured whether households were able to afford balanced meals if meals had been downsized or skipped because there was not enough money for food the frequency of these events and how often household members experienced hunger these responses were used by statistics canada to categorize households into four levels of food security high marginal low and very low 28 in the analyses highly secure and marginally secure were combined into one category covariates in addition to household food insecurity covariates included demographic household school geographic and cultural variables previously identified as having potential relationships with food insecurity or obesity the demographic variables included were indigenous identity group age and gender household socioeconomic characteristics included annual household income and mothers educational attainment household income was divided by the number of household members to provide a per capita household measure which was included as quartiles other household characteristics included family structure as well as household crowding which was measured based on the number of people per room the aps included questions about the school environment respondents were asked to indicate their level of agreement using a fourpoint scale with eight statements aspects of a positive school environment were captured by asking 1 overall respondent feelsfelt safe at school 2 overall respondent iswas happy at school 3 most children enjoyenjoyed being at school and 4 the school providesprovided many opportunities to be involved in school activities negative aspects of the school environment were captured by agreement with 1 racism iswas a problem at school 2 bullying iswas a problem at school 3 the presence of alcohol iswas a problem at school 4 the presence of drugs iswas a problem at school and 5 violence iswas a problem at school for each child responses to the positive and negative environment questions were averaged so that higher scores indicate more positive or more negative environments regional and urbanrural geography were also part of the analysis as research strongly suggests the importance of broader environmental factors lastly the cultural variables exposure to indigenous language and family members attendance of residential schools were also included to capture their potential influence on childrens weight status it has been suggested that cultural characteristics such as language retention are important for indigenous peoples health in general and previous research using the 2006 aps has found that parental residential school attendance was predictive of obesity among métis children 922 children who were reported to be exposed to an aboriginal language at home or outside the home were coded as exposed the aps asked whether the childs pmk or the pmks mother or father had attended indian residential or industrial schools those who did not respond to these questions were retained as a separate category called not stated statistical analyses we used pearson chisquare tests to assess bivariate associations between the independent variables and obesity thereafter we used a binary multivariate logistic regression to test the likelihood of children and youth having bmi in the normal range versus being overweight or obese cond itional on the independent variables that we found to have significant bivariate associations with overweight and obesity a total of five nested models were fitted including different groups of predictor variables we performed our statistical analysis using sas software version 94 29 we used bootstrap weights provided by statistics canada and balanced repeated reestimation to adjust variance estimates for the surveys complex sampling design results table 1 independent of the other variables but first nations and métis children in british columbia and the three territories were less likely to be overweight or obese controlling for the other variables in the model lastly model v included the two cultural variablesexposure to an indigenous language and family members having attended residential schools neither had a significant independent effect on obesity status discussion this study provides additional evidence that indigenous children and youth are at higher risk of overweight and obesity than are other canadian children among youth aged 12 to 17 years in our study sample 30 were classified as either overweight or obese compared with 207 of all canadian youth in 2013 30 first nations and métis girls were less likely to be overweight or obese than were boys an observation that is consistent with previous literature on weight status and sex gender 163132 given that indigenous children and youth are at a higher risk of overweight and obesity and the potential for weight to impact health outcomes over the life course 3 4 5 6 7 it is important to understand the distal and upstream determinants that drive their weight status the data shown here support the importance and utility of a socioecological perspective for those ends 8 there has been little exploration of the relationship between food security and weight status among indigenous children and youth despite research suggesting its importance for the health of aboriginal peoples more generally 33 research on the relationship between food insecurity and obesity or overweight among children and youth has thus far been inconclusive as studies have found either a positive association between food insecurity and obesity 15 34 35 36 or insignificant results 37 38 39 there are only a few canadian studies exam ining the food insecurityobesity relationship 144041 overall this study found that food insecurity is indeed a risk factor for overweight or obesity among indigenous children with children in very foodinsecure households having significantly higher odds of experienced low food security and 68 were severely food insecure there were significant differences in the percentage of children and youth classified as normal overweight and obese for all of the covariates examined at the individual level among those who experienced very low food security 277 were overweight and 192 were obese age was a critical factor for weight status as 473 of aboriginal children between the ages of 6 and 11 years were either overweight or obese compared to 30 of youth aged 12 to 17 years a larger proportion of males fell into the overweight or obese classification compared to females indigenous identity also had a marginal impact on the likelihood of overweight or obese weight status as 40 of first nations children fell into these weight categories compared with 34 of métis children children and youth who were exposed to an aboriginal language were more likely to be overweight or obese compared to those who had no exposure the familylevel variables also tell an interesting story the proportion of overweight or obese children does not largely differ based on mothers educational attainment 41 of children whose mothers had less than secondary school graduation were overweight or obese and approximately 35 of children whose mothers obtained a postsecondary certificate diploma or degree fell into these weight categories almost half of children from the lowest income quartile were overweight or obese the proportion of children from twoparent families classified as overweight or obese was almost six percentage points less than children from loneparent families but similar to the proportion of overweight and obesity among children who lived in other family structures of children and youth living in households where there was more than one person per room 400 were classified as overweight or obese compared to 372 of children living in households with one or fewer people per room while 17 of the sample did not respond to the question about a family member attending residential schools children whose family members had attended residential schools had a higher proportion of overweight or obese status compared to those who did not the regional and urbanrural geography variables showed that almost 40 of aboriginal children and youth living in the atlantic provinces quebec and ontario were either overweight or obese in small population centres the proportion of children and youth who were overweight or obese was 425 followed by medium population centres large population centres and rural areas the bivariate relationships between the school environment variables and overweight were unclear children and youth in school environments that were rated the most positive were the most likely to be obese although those in the third quartile were the least likely to be obese those rating their school environments the least negatively were the most likely to be obese while those with the most negative school environment rating were the least likely we investigated the adjusted associations between these variables and childrens weight status using sequential multivariate logistic regression in model i only food security and demographic variables were included and those with very low food security had higher odds of being obese or overweight in model ii other household variables were added and the effect of food security fell below significance mothers educational attainment family structure and crowding had no significant independent effects but those in the third and fourth income quartiles were significantly less likely to be overweight or obese than those in the first quartile school environment variables were added in model iii a positive school environment rating was unrelated to overweight or obesity while those in the second third and fourth quartiles of negative school environment were more likely to be overweight or obese than those in the first quartile those whose school environments were rated the most negatively were the most likely to be overweight or obese relative to those who rated their school environments the least negatively model iv added geographic variables rural or urban residence had no effect household socioeconomic and demographic characteristics understanding these results requires further investigation but it has been suggested elsewhere that schools with negative climates may also be less likely to offer effective opportunities for physical activity 42 regional geography appeared to have an impact on weight status as children and youth living in british columbia or the three territories were significantly less likely to be overweight or obese compared to children living in ontario controlling for household socioeconomic characteristics similar variation has been observed previously and some research suggests that greater emphasis on outdoor physical activity and availability of facilities may be partially responsible for the observed difference in weight status across provinces 43 in addition socioeconomic status 4445 as well as being born outside of canada 44 has been inversely associated with a lower bmi among adults in several provinces including british columbia somewhat surprisingly however there was no difference between indigenous children and youth living in rural small medium or large cities in their odds of being overweight or obese suggesting that the more important factors were operating at the household and school levels given previous literature on the determinants of indigenous peoples health we had expected to find that exposure to an indigenous language as a measure of cultural preservation would be protective against being overweight or obese and that having a family member who attended residential schools would be a risk factor although neither had an independent effect it must be recognized that these measures included in the aps are only weak measures of cultural attachment or preservation further research is necessary to understand whether cultural factors might be related to overweight and obesity at the population level and if so in what way strengths and limitations no other studies to date have examined the relationship between food insecurity and obesity among aboriginal children and youth at the population level this study used a national survey with the largest available sample size of indigenous children and youth a key limitation of this study as well as many others investigating the food insecurityobesity relationship is that the design is crosssectional and does not allow us to establish causation or explore how the relationship changes over time subjective bmi data were collected as caregivers were asked to report their childrens height and weight this may have resulted in an underestimate of the prevalence of obesity as research shows that parents tend to underestimate their childrens weight and overestimate height leading to a lower bmi than when objectively measured 4546 covariates not measured in this study such as physical activity and diet could be responsible for confounding effects additionally given that this is not a wellstudied topic we were not able to compare this association in aboriginal children and youth with any similar associations in the general canadian population it is also difficult to compare our results with other studies because different measures are used to assess food insecurity the united states uses the agricultural department food security scale 47 which is different from the measures used in the aps or the canadian community health survey limiting comparisons moreover while the literature discusses the importance of including culture and access to traditional foods for an aboriginal definition of food security 89 the aps food security questions do not include these dimensions conclusion we concluded that offreserve indigenous children and youth who are in households with very low food security are indeed at higher risk for overweight and obesity but that this excess risk is not independent of household socioeconomic status household income adjusted for household size are reliable predictors this suggests that household socioeconomic status is a major contributor to the high risk of overweight and obesity among first nations and métis children and youth we also found that being in a negative school environment is associated with obesity risk independent of demographic household and geographic factors given the complexity of childhood obesity and overweight the available data limited our ability to identify conclusively the factors that are most important including the potential role of food insecurity there is a lack of longitudinal data to help us understand the interplay of various factors over the life course in different populations among indigenous peoples specifically communitybased participatory research and research using qualitative methods would strongly complement quantitative investigations previous research on interventions in aboriginal communities demonstrates the strength of such an approach 334142 conflicts of interest the authors report no conflicts of interest the authors alone are responsible for the content and writing of the paper

introduction indigenous children are twice as likely to be classified as obese and three times as likely to experience household food insecurity when compared with nonindigenous canadian children the purpose of this study was to explore the relationship between food insecurity and weight status among métis and offreserve first nations children and youth across canadawe obtained data on children and youth aged 6 to 17 years n 6900 from the 2012 aboriginal peoples survey we tested bivariate relationships using pearson chisquare tests and used nested binary logistic regressions to examine the food insecurityweight status relationship after controlling for geography household and school characteristics and cultural factors results approximately 22 of métis and first nations children and youth were overweight and 15 were classified as obese over 80 of the sample was reported as food secure 9 experienced low food security and 7 were severely food insecure offreserve indigenous children and youth from households with very low food security were at higher risk of overweight or obese status however this excess risk was not independent of household socioeconomic status and was reduced by controlling for household income adjusted for household size negative school environment was also a significant predictor of obesity risk independent of demographic household and geographic factorsboth food insecurity and obesity were prevalent among the indigenous groups studied and our results suggest that a large proportion of children and youth who are food insecure are also overweight or obese this study reinforces the importance of including social determinants of health such as income school environment and geography in programs or policies targeting child obesity

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introduction the notion of the positive effects of art is traced to aristotles poetics where he coined the term catharsis the arts are understood to redefine peoples relationship to the world by being an extension of themselves today the understanding that the arts can positively impact individuals and societies is still widespread this article presents the result of a stateoftheart literature review made within the amass project involving researchers and artists from the czech republic finland hungary italy malta sweden uk and portugal the review aims to survey existing knowledge on the role of the arts in tackling social marginalisation it accompanies a systematic literature review made within the project that evaluated current research on the social impact of the arts the present article is based on complementary summaries of socalled grey literature research reports dissertations government documents and research in languages other than english with this article we analyse the role of the arts as it is understood in our material in relation to the positioning of the problem of marginalisation we ask the following questions what are the social problems identified in the material to which the arts can function as a solution or as a way to address the identified problem where is the cause of the problem localised ie what understandings of the root of the problem arise in the material the analysis is not to be interpreted as actual or given evidence of the effects of arts but rather a reflection of common understandings of the role of arts in relation to social issues of marginalisation data collection and method of approach when collecting the data fellow researchers in each country in the amass project collected data through a template for abstracts searching literature through databases of their own choice based on their knowledge of where to find relevant literature in their language however we asked them to use a model for understanding populations interventions and outcomes in the material cf arguelles posições por meio da compreensão de suas qualidades educacionais essas categorias oferecem um papel frutífero mas também potencialmente limitado das artes na sociedade palavraschave revisão de literatura literatura cinzenta artes para a transformação social política cultural resumen en este artículo presentamos el análisis de una revisión realizada como parte del proyecto amass financiado por la ue horizonte 2020 que tiene como objetivo abordar los desafíos de la marginación en europa a través de intervenciones basadas en las artes este estudio analiza materiales basados en investigaciones sobre el impacto social de las artes teóricamente sustentados por una comprensión del papel de las artes en conjunto con la problematización de la marginación social encontramos tres formas de entender el impacto social de las artes en el material como un medio participativo de agencia y empoderamiento identidad y expresión y aprendizaje y desarrollo estas categorías están relacionadas con posiciones de marginación derivadas analíticamente como predominantemente estructurales o más basadas en el individuo el arte se concibe como una forma de tender un puente entre estas posiciones a través de la comprensión de sus cualidades educativas estas categorías ofrecen un papel fructífero pero también potencialmente limitado de las artes en la sociedad palavras clave revisión de la literatura literatura gris artes socialmente comprometidas política cultural 2011 this model with variations is used in systematic literature reviews and was chosen to help our partners generate limited and focused key words for search strings and relevant hits in databases in the data collection process populations are those targeted by artistic interventions which are projects involving art in various contexts outcomes are understood as the intended or perceived results of the interventions the material included peerreviewed research articles in all languages except english researchbased reports and monographs in english not included in the systematic literature review to avoid duplicate findings in total the review is based upon 234 abstracts of research thus our interpretations are based on research material interpreted and translated by the members of the amass project our understanding of marginalisation is not derived from a reality independent of the empirical material submitted by project members who selected research relevant following the predefined criteria the material analysed is thus chosen to highlight the themes and problematisations targeted in the amass project and partially reflects studies made by the members of the amass consortium for example our partners in the data collection process displayed varying understandings of the categories population intervention and outcome which we untangled in the analysis by creating subcategories in several interpretative levels the material may show a bias towards ideas of the positive impact of the arts and culture on social issues such as marginalisation the majority of abstracts from finland and hungary may also skew the data in the direction of the kinds of research performed in these countries according to the previous model of population intervention and outcomes the first step of the analysis was to understand descriptive patterns in the data we also studied what kinds of art forms were present in the material this interpretative stage is not displayed in the results of this study as it focuses on an additional stage of analysis a second step where we engaged in a thematic approach inspired by the works of carol bacchi in this framework social issues are problematised or represented as social problems which in a foucauldian sense would signify the unexamined ways of thinking that guide the practices of governance thus instead of addressing social problems as though given and obvious we look at the way they are given shape such that certain solutions are desirable to come to terms with a problem the representation of problems helps us understand the arts as a means of making a social impact on marginalised communities results in the analysis we found a variety of art forms in interventions design participatory arts narrative arts music dance theatredrama and visual arts these were incorporated into interventions that often targeted communities such as in segregated areas of cities or rural places specific target groups were typically children and young people migrants minorities elderly women and people with physical or cognitive handicaps thus there are many ways to understand and address social marginalisation problems in the material next we turned our analysis to the understanding of these problems and their localisation below we present the analysis with examples of representative studies to demonstrate the width of research in different national contexts and languages the positioning of the problem of social marginalisation the analysis identified one broad problematisation in the data social exclusion which takes different forms of expression at a general level social exclusion is understood as the marginalisation of minority communities and vulnerable citizens in society social exclusion is perceived as a lack of participation in the arts from parts of the community or parts of the demography the analys found two very typical for social analysis positions of the problem of social exclusion as a structural issue and in the marginalised on a groupcommunity and individual level these positionings are not clearcut they overlap but are roughly related to different understandings of the role of art in society as a means to agency and empowerment or as a means to identity and expression there are attempts in the material to form bridges between structural and individual problematisations mainly through understanding art as learning and development in the following we will elaborate on how these positions are expressed in the material social exclusion positioned as a structural problem social exclusion is understood as caused by negative perceptions among the wider community towards minorities and other marginalised social groups ie discrimination racism and segregation the material critically responds to negative and stereotyped representations of minority residents and other underrepresented populations as outsiders the notion of marginalisation does not necessarily represent the marginalised but may be defined by an unproblematised majority society and its normative structures there is a desire to include on the terms of the majority society which raises questions as to inclusion for what and whom minority cultures are described in terms of considerable disadvantage visàvis the wider community to this end artsbased projects aim to understand the realities of marginalised communities tackle harmful social divisions act for social justice and diversity and promote participation and cultural expression however it is also pointed out with reference to szontagh that strengthening social inclusion should not be confused with the fight against segregation the latter is described as momentary solutions causing tensions in ethnic and cultural division authors such as buttu and molnár peták vercseg problematise the idea of community development as a solution to tackling social problems and claims that support must be continuous and not remain a temporary intervention although the structural position of the problem of marginalisation problematises the scope of the arts as a means to address social exclusion the role of the arts is largely understood as a means to empowerment and participation interventions based on participatory art have been considered an innovative approach that supports change which requires awareness of the wider context in which social change occurs an example of a structurally oriented approach is how the school system is problematised as poorly adjusted to disabled pupils and how educational inequality requires efforts to come to terms with parental poverty action or practicebased methods are standard in our material community interventions are often carried out with an eye to the social and communitarian aspects of art as indicated by terms like socialcommunity art or theatre the more these socially engaged aspects of art tend to promote the interests of community members the more impact they are deemed to have and the more they may give voice to community members creativity experiences interests and needs also small grassroots museums in areas labelled as socially deprived may carry out various sociocultural events that empower the community in close cooperation with local groups for much the same reason it has been claimed that a successful museum of the future should be wholly participatory through meaningful collaboration between curators and communities in several projects the purpose is to explore the sense of european citizenship among children and young people engaging young people in the development of democracy and exercising their rights as citizens have been put forward to contribute to a higher level of awareness of european priorities such as citizenship participation cultural diversity and inclusion social exclusion positioned as a problem in the marginalised inequality caused by social exclusion is understood to hamper not only opportunities to learn but also to develop critical individual skills and competencies and improve individual quality of life weak social and communication skills of people caught in social and economic deprivation is understood in the material to be due to lack of educational means not only in a formal sense but also in the sense of facing barriers to community participation and limitations as regards selfsustainability the individualistic perspective can be taken concerning groups of identified common marginalised positions such as the elderly migrant or children deemed in need of societal support or greater access to societal resources such as the arts however in contrast to the structural positioning of the problem the problem here lies in the ability of the individuals in the group to enhance their lives contributing to and learning more about how to secure the welfare of children and youth in a vulnerable situation is a concern in many projects outreach activities concerning the young have aimed at letting young people express their identities the opportunity for children to experience the arts is said to develop a sensibility that projects them towards a future as adults conscious of the importance of dreaming studies have called continued attention to the need to rethink pedagogical methods to ensure equal opportunities for learning for disadvantaged groups ensure that no talent is wasted and reduce early school leaving the process of learning through artistic creation is sometimes thought to be built into the personality of the individual pupil there is a belief that each pupil may be motivated to learn and develop with the right kind of training tailored to his or her individual needs above all musical activities have been a frequent method of intervention to help the learning and development of young roma talents the question remains how to secure equal access and eliminate what has used to be a highly segregated character of education expression of the role of the arts to this more individualised positioning of the problem is a matter of giving marginalised groups and community residents the tools for telling their own stories on their terms hence to take upon themselves an active role as agents of change as a cornerstone in the preservation of roma culture and heritage it is also argued that through art the roma can speak for themselves and create selfimages in contrast to mainstream media representations of roma people agency is constructed as a way to provide these groups with better livelihoods and in general this positioning of the problem allows for a more positive understanding of the scope of the arts as a means to address social exclusion with increasing migration to europe in 2015 and onwards migrants have frequently been represented either as victims or invaders some projects have been claimed to allow migrants to build links to their new community while also remembering their home countries the preservation of cultural identities as part of the majority society is a central point regarding the social inclusion of people with an immigrant background yet interventions directed towards migrants and minorities have also focused to a great extent on reactions and ideas about the experience of otherness and thus targeting the means to express an identity rather than structural racism furthermore elderly or retired people are another identifiable target group whose wellbeing quality of life and life management are the concerns of several projects aimed at assessing and improving the care and services for seniors either in sparsely populated areas or in the cities the problem can also be positioned as a problem for the ones trying to reach out through the arts an issue mentioned in one of the abstracts is how to overcome barriers between social and artistic domains thus the issue is patterns of nonparticipation in the arts interpreted as barriers that hinder the marginalised to access the arts as a means of selfexpression and selfdevelopment on an individual group or a community level for example one project summary implies that it is difficult for nonroma people to manage the process of empowering this group unless there is a permanent presence in the community and the community members trust may be gained it is said to be difficult to become accepted and be able to influence the roma thus several projects aim to explore practical tools and artistic methods for reaching out to vulnerable communities since a lack of political action to provide guidelines for tackling these issues in their entirety is pointed out connecting the structural and the individual levels the analytical separation between positionings of the problem does not imply as earlier stated that researchers and practitioners cannot imagine social problems as multifaceted and complex on the contrary attempts to overcome structural and individual perspectives dominate the material the concept of connective art suggests that the social actions of the people who inhabit collective spaces contribute to the construction of the communitys collective memory and experience and thus expresses the identity of a community and its members connectivity through meetings between community members allows for exchanging such collective experiences other activities such as wall painting are described to allow communities to express their interests and identity creatively with a critical and interventional eye and understanding that the society could participate in their development in an equal way such projects are said to set the ground for future development through the opportunities for collaborative meetings of various kinds that transformed marginalised places policy development efforts to achieve diversification of cultural services and removal of barriers to access and inclusion have been exemplified by continuous community consultation outreach programs partnerships with local agencies training courses et cetera these interventions have been claimed to have an impact on the individual community and institutional levels resulting not only in increased cultural exchange and participation but also improved wellbeing trust and selfesteem a sense of identity and belonging to a community as well as reduced social isolation above all the artistic interventions summarised in the abstracts attempt to interlink the structural and individual domains through various educational efforts art education aimed at learning and development in a community context may provide community members with a selfreflexive awareness that further supports agency emancipation empowerment and sensemaking the arts are seen as possessing a certain kind of knowledge production apt for understanding complex social issues art is primarily described as a means of generating knowledge and enriched learning outcomes in response to major social problems as a way to understand the lives of marginalised subjects better and to promote more inclusive environments for them to subsist securing equal learning opportunities may be interpreted as a precondition for equal access to the arts and vice versa since art and learning are interpreted in the abstracts as interwoven it is nevertheless argued that a traditional educational structure does not always give much room for arts education learning opportunities within the arts and culture need to be extended into the community as a whole to be a means to the empowerment of marginalised groups targeting particular groups of community members is seen to connect personal narratives with social interaction by focusing on the societal issues that affect personal everyday life for instance seniors may be actively engaged in cultural activities but are considered at risk of marginalisation as experiencing loneliness and isolation according to one abstract there is potential for participatory arts with older people to address loneliness and social isolation and by extension it strengthens ties to the community and facilitates social interaction and cohesion likewise young people and their wellbeing are tied to structural changes and community needs in times of increasing urbanisation there is an urge to keep the remote areas of the north alive and the young are seen as key to this endeavour in one project visual art activities involving metal sculpture photography and wall art with young people in lapland were reported to support young rural finns wellbeing finally another theme in the abstracts is to link the history traditions and ways of earning a living for women in particular settings and understanding the appreciation of women in society at large traditional crafts have often been vital not only to the sense of female agency but also to national identity as these crafts have become obsolete the abstracts describe a struggle to raise awareness and keep these womens movements alive thus there is a link between selfexpression and representation that in turn affect social participation through education conclusion and discussion this review has covered collected artsbased research and policy materials concerning social issues of social exclusion and marginalisation the themes have been distinguished in a spectrum of projects ranging from the ones being described as targeted at specific groups of individuals to those directed towards whole communities and in extension structural levels of social problems the interventions in the material are often practiceoriented and characterised by the approaches to the contextualisation analysis evaluation and communication of the perceived results of interventions in relation to these positionings of the problem two ambitions emerge in the data regarding outcomes 1 to add to existing knowledge regarding the role of arts concerning societal challenges or 2 address the social challenge and be part of a solution these positions broadly reflect a debate in social research whether science should have a normative agenda or merely offer insight in the material the arts are understood to address problems that arise on structural individual and in some ways practicebased levels to bridge these levels art is associated with learning skills and in turn learning skills are associated with an agency to change things on multiple levels we found three ways to understand the social impact of the arts in the material as a participatory means to agency and empowerment identity and expression and learning and development these all have in common that they represent arts perceived potential to connect the social and artistic domains and to some extent challenge traditional conceptions of art as a matter of purely aesthetic objects the material studies reflect an idea that the performative potential of art to achieve social change lies in its way of expressing and extending ourselves to a diversity of social realities importantly art is understood as situated and thus a product of a socially and historically specific context in which humans themselves are the agents capable of transforming their lives and reality however in this type of meaningmaking of art the root causes of marginalisation are sometimes left unaddressed abstracts discussing the problem of marginalisation on the structural level adds an analysis of causes yet the interventions are still targeting those affected by the causes not those forces that cause marginalisation artists and arts educators risk partaking in the responsibilisation of marginalisation on the marginalised what more the arts become limited to helping the marginalised cope with their situation rather than problematising takenforgranted structures in european societies that cause issues of marginalisation

in this article we present the analysis of a stateoftheart review made as part of the horizon 2020 eufunded project amass acting on the margins arts as social sculpture which aims to address challenges of marginalisation in europe through artsbased interventions this study analyses researchedbased materials on the social impact of the arts theoretically underpinned by an understanding of the role of the arts in conjunction with the problematisation of social marginalisation we found three ways to understand the social impact of the arts in the material as a participatory means to agency and empowerment identity and expression and learning and development these categories are related to analytically derived positions of marginalisation as predominantly structuralor more individualbased art is conceived of as a way to bridge these positions through an understanding of its educational qualities these categories offer a fruitful but also potentially limited role of the arts in society

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to accomplish this goal we constructed a database of homicide rates within the region by piecing together statistics published by the united nations and the world health organization various national and international police records and data from published work we then merged this information with event history data compiled from the mexican migration project and the latin american migration project by combining longitudinal homicide trends with histories of emigration from selected nations we could directly assess the effect of deadly violence on the odds of initiating migration to the united states in our analysis we focused on households and predicted whether and when each household would first send a migrant to the united states we undertook pooled as well as countryspecific analyses to understand how violence affects migration across the region as well as within specific nations violence and international migration the literature reflects a paucity of research on the relationship between violence and migration a systematic online search yielded just thirtyseven published articles in the fields of sociology and public health of these only five were relevant to the current project and none dealt directly with how violence by itself affected migration in any part of the world no doubt this gap at least partially reflects the lack of data and other methodological constraints rather than a lack of interest in violence as a factor influencing migration indeed the enormous literature on refugees asylum seekers and displaced persons clearly suggests that people are interested in connections between violence and migration nevertheless the two phenomena are seldom modeled together directly our aim here is to illuminate the influence of violencein its most extreme form and at the macro levelon the decision to leave ones place of origin in search of a more secure future elsewhere we situate our analysis within world systems theory which views migration in the context of macrolevel economic restructuring and hypothesizes that migration and violence are common byproducts of societal transformations associated with the globalization of markets this perspective stands in contrast to that of neoclassical economics which conceptualizes migration as an individual decision to maximize earnings and thus equilibrate labor supply and demand between regions in terms of decision making our analysis is modeled more closely on the new economics of labor migration which views migrants not as atomized agents but as members of larger social units such as households and communities each nation has its own specific history of economic development and violence in guatemala and nicaragua prolonged armed conflict and usled covert operations conform to world systems theorys military links hypothesis which holds that military interventions undertaken by core nations to protect overseas investments and guarantee free trade inevitably establish ancillary social and political ties upon which migration later develops in addition to displacing people directly from areas of violent conflict military interventions create social connections and moral debts that displaced persons can draw upon to gain entry to core nations at the same time intervention plants seeds for future violence and emigration by distributing arms materiel and training to large numbers of people whose violent acts subsequently disrupt local markets costa rica and mexico exemplify another hypothesis derived from world systems theory the market penetration hypothesis which argues that the transformative effects of markets on local social and economic structures displaces people from traditional livelihoods to create a pool of people prone to migration the north american free trade agreement and the central american free trade agreement are clear examples of how market mechanisms imposed from outside end up promoting not only crossborder movements of goods capital commodities and resources but also of people a critical mechanism by which violence occurs in the context of market penetration is the consolidation of landholding and the mechanization of production which together create a population of economically marginalized and socially displaced agrarian workers these dislocations are often accompanied by violent acts as elites use force to impose marketoriented policies from above and the poor resist these impositions societal dislocations also promote violence by reducing the number of local jobs causing people to turn to various blackmarket activities including crime as a means of survival societal transformations associated with the growth and elaboration of markets also undermine traditional mechanisms of social regulation and control modernization theory also hypothesizes a strong connection between crime and economic transformation and takes as its point of departure durkheims work on the consequences of modernization durkheim argued that as societies shift from traditional to modern modes of economic organization older social practices and norms come to be at odds with those of the new market economy yielding a period of social instability and anomie modernization theory thus posits that instability and dislocation are direct results of the introduction of modern economic relations into a developingcountry context merton messner androsenfeld andsavolainen have taken durkheims concept of anomie and applied it to study modernizations influence on rates of crime and social deviance likewise davies and smelser have adopted the notion of social disorganization to explain the association between modernization and social deviance still others have applied the concept of social breakdown to the fundamental process rooted in durkheims work on the social costs of modernization finally the closely related concepts of tension and strain have also worked their way into the literature to explain how the transition to modernity has the power to weaken traditional social bonds and disrupt longestablished social norms modernization theorys two major weaknesses are its lack of specificity about the term modern and its assumption that all societies transit from one regime to the other at the same rate nonetheless by predicting violence as a byproduct of economic development it offers a conceptual framework for theorizing the effect of violence on migration in combination with world systems theory modernization theory suggests a mechanism by which economic change leads to emigration through the intervening variable of violence increases in social dislocation anomie and crime stemming from economic development increase the potential for social marginalization criminality and violence which in turn lead to increased migration it is this logic derived from both world systems theory and modernization theory that leads us to hypothesize an increase in homicide rates over time and a corresponding rise in the likelihood of migration to the united states data and methods definitions of variables used in our analysis are presented in table 1 to measure the level of violence prevailing in each country during each year from 1979 to 2003 we turn to homicide data published by the united nations and the world health organization national police records and information compiled by pebley and roserobixby several authors have reviewed in some detail the strengths and weaknesses of these data sources the united nations crime survey data are generally considered flawed because they depend on reports from each member nations criminal justice systems these data provide information on homicides during the period 1970 through 1994 in his review neapolitan concluded that the fourth wave of the un crime trends survey from 1986 through 1990 was most suitable for meaningful research given major advances in the construction of the survey and the collection of the data the un provided assistance to developing nations in record keeping which resulted in more consistent and trustworthy homicide data the fourth uncs included rich data from one hundred nations about total homicides total intended homicides attempted intended homicides nonintentional homicides and other major criminal offenses the who in contrast tabulates yearly cause of death information from actual death certificates collected by public health agencies which are published each year in world health statistics annual these data do not rely on police records and therefore do not suffer from institutional constraints on record keepingthe who defines homicide as any act performed with the purpose of taking human life in whatever circumstances the cause category from which we take our data is homicide and injury purposely inflicted by other persons ignoring the ambiguous category other violence the consensus among researchers who study crossnational crime trends and homicide rates is that the who data are the most reliable so whenever possible we relied on that data we drew on the un and other sources mainly to fill gaps in the who series national police records have historically been condemned as the least reliable source of homicide data because of their reliance on police chiefs and captains to report the crimes and because of a lack of governmental oversight still police records allowed us to fill in some of the few gaps that remained after looking at un and who data last we included data from pebley and roserobixby to complement the foregoing sources using these sources together with national police records we were able to fill in gaps in homicide data for the primary conflict years in nicaragua combining information from all sources we derived a data set that was almost complete for all countries and years between 1979and 2003save for 1979in costa rica and nicaragua and 1982 1983 and 1985 in guatemala we filled in these gaps using linear interpolation we then smoothed the resulting series by taking threeyear moving averages to control for random yeartoyear fluctuations we merged the homicide data series with data from the mmp and lamp the mmp is a retrospective longitudinal study begun in 1982 that annually surveys a representative sample of households in selected mexican communities to identify and study persons with migratory experience in the united states the 118 communities surveyed to date were chosen to represent a diverse range of population sizes economic bases ethnic compositions and regions to ensure that though not randomly selected they nonetheless provide a broad cross section of the population at risk of migrating to the united states in addition to gathering basic data on the social demographic and economic characteristics of households and individuals the survey ascertained the dates of the first and most recent trips to the united states for each household member and the household head and spouse also provided complete life histories that yielded a yearbyyear record of changing individual and household circumstances the lamp was modeled on the mmp and used the same design and survey instruments to gather information on international migration from other countries in latin america from the lamp we used data from communities surveyed in costa rica guatemala and nicaragua to assess how migration processes differ between mexico and other spanishspeaking nations in the same geographic region the lamp data set which began in 1998 also allows for a yearbyyear analysis of migration patterns controlling for relevant social demographic and economic characteristics following lundquist and massey we constructed an event history for each household in each community households were followed from their inception until the survey date or the date of the first us trip whichever came first we identified the year in which any household member undertook a first us trip whereas in mexico first trips are most frequently undertaken by household heads in central america they are more often made by older children of the head especially sons moreover since first migration in both settings is a maledominated phenomenon we restricted our analyses to male departures only the construction of householdyear files for the entire household rather than personyear files for household heads allowed for a more direct comparison among settings it also yielded greater variance on the dependent variable in addition to developing overall indicators of violence we assessed changing conditions in the national political economy we measured overall economic performance by expressing each nations gross domestic product per capita relative to that of the united states yielding an indicator of the relative size of the earnings gapthe leading theoretical predictor of neoclassical economics to measure the extent to which neoliberal economic policies were functioning each year we drew on heston summers and atens index of economic openness which is defined as the value of total trade divided by national gdp finally in the case of nicaragua where us intervention has been shown to have been critical in promoting emigration to the united states we use the indicator of us contra involvement developed by lundquist and massey which is essentially a yearly count of mentions of contras or contra violence in us papers and magazines table 1 also defines the householdlevel independent variables we included in our model demographic predictors of first us migration include the heads age and its square to capture the characteristic inverted parabolic distribution of migration over the life course we also include the number of minors in the household to measure household dependency indicator variables for assets include whether or not during the year in question the household owned farmland real estate or a business enterprise we control for human capital by including years of schooling for both the head and the spouse social capital is measured by counting the number of immediate family members of the head with prior experience in the united states and the heads labor force status by a series of dummy variables indicating whether he undertook unskilled manual work or skilled manual work or was unemployed leaving agricultural work as the reference category we also measure whether or not the spouse was unemployed during the personyear in question table 2 shows means standard deviations minima and maxima for each covariate in our pooled sample these statistics reveal substantial variation in homicide rates across the sample with the crude rate ranging from a low of 66 to a high of 2135 murders per 100000 although we do not show figures for individual countries in the table variation in the sample is both geographic and temporal the average murder rate was lowest in costa rica at 101 followed by 329 in mexico 449 in nicaragua and 544 in guatemala thus the average risk of lethal violence was more than five times greater in guatemala than in costa rica homicide rates in costa rica were not only the lowest but also the most consistent over time varying within a narrow range from 85 to 121 in contrast guatemalas rate ranged from a high of 2135 to a low of just 66 and nicaraguas ranged from 819 to 62 across all householdyears heads averaged 34 years of age and lived in a home with 17 minors around 12 percent owned farmland 49 percent possessed urban real estate and 13 percent had a business enterprise household heads averaged 66 years of schooling their spouses reported an average of 61 years in the average personyear the typical household head was employed with most working in agriculture or services and fewer than a quarter of heads reported having an employed spouse to assess the independent influence of violence on the likelihood of initial migration to the united states we undertook a series of multivariate discretetime event history analyses of first us departure from households in mexico costa rica guatemala and nicaragua multiple imputation provided us with complete data for all covariates and allowed us to estimate models that averaged the coefficients and corrected the standard errors for distinct regression analyses run on the five multiple imputed data sets the data were organized in a timetoevent format that followed each household year by year up to the point of initial migration or righthand censoring rendering discretetime analysis appropriate for estimating survival models discrete and continuous time methods produce nearly identical results and estimated standard errors suffer little from the loss of information associated with not knowing the exact time when an event occurs since our data are organized into yearly intervals we refer to each record as a householdyear we define the onset of risk for migration to begin in 1979 and the end of risk at the time of first migration or survey date all models are lagged so that the dependent variablethe migration of the first household member to the united statesis defined in year t and independent variables in year t 1 all variables except education and country are time varying although education in theory is time varying in practice it is fixed prior to household formation we estimate a pooled model for all countries combined including dummy variables to control for country fixed effects as well as countryspecific models to allow for countryspecific interactions trends in structural adjustment violence and migration we summarize each nations structural transformation from import substitution industrialization to neoliberalism in figure 1 which plots economic openness and relative gdp by year from 1979 to 2002 all four nations were subject to import substitution restrictions and remained substantially closed to international trade through the early to mid1980s when there was a pronounced shift toward neoliberalism mexico for example remained substantially closed to trade with an openness index that hovered around 20 percent through 1986 when it joined the general agreement on tariffs and trade after 1986 its openness index began to rise steadily to the point where international trade accounted for more than 60 percent of gdp by 2002 although costa rica has always been more open to trade and investment than mexico its trend toward greater openness over time is quite similar the openness index for costa rica fluctuated between 40 and 50 percent until 1986 and then rose to peak at values above 90 percent at the end of the century in contrast both guatemala and nicaragua experienced declining openness between 1979 and the end of the 1980s in nicaragua for example the period between when the sandinista regime took control in 1979 when the region was engulfed in civil strife and 1987 when the contra war began to wind down there was a sustained reduction of economic openness then there was a sudden surge toward openness from 1987 through 1989 which fell back temporarily in 1991 before rising once again and ultimately coming to exceed that observed in mexico although neoliberal reforms were also applied in guatemala the transition to an open economy was slower and less complete with the openness index going from around 27 percent in 1986 to just 49 percent in 2001 the lowest level of any of the four countries despite national differences in the timing and ultimate achievement of an open economy in terms of relative economic performance the story was quite similar across countries as figure 1 shows there was a steady decline in relative gdp in each nation from the early 1980s onward the deterioration in relative earnings was notably marked in guatemala and nicaragua even though costa rica and mexico fared better the size of the national income gap with the united states still widened in both places thus the shift toward neoliberalism was accompanied by falling relative incomes in mexico and central america some observers have associated the dislocations of structural adjustment and the concomitant deterioration in earnings with a rise in crime and social disorder but the plots shown in figure 2 offer little support for this hypothesis the figure shows trends in smoothed homicide rates from 1979 through 2002 for each of the four nations in guatemala the peak of lethal violence occurred in the early 1980s when the economy was still closed whereas in mexico the homicide rate actually fell slightly through the later 1990s as the economy shifted toward openness and incomes deteriorated in costa rica meanwhile there is little or no trend in homicide at all despite a strong shift toward openness only in nicaragua is there a gradual rise in lethal violence that corresponds in time with the shift toward economic openness and deteriorating incomes if there is a relationship between structural adjustment and violence therefore it appears to be more complex than a simple onetoone correspondence and likely contingent on countryspecific conditions yearly migration probabilities are shown in figure 3 these were calculated by estimating an event history model that predicted outmigration from households in year t from dummy variables defined to indicate each year once again these figures suggest no simple correspondence between structural adjustment or violence and outmigration to the united states in guatemala the likelihood that a household would initiate international migration rose and fell in three oscillations between 1980 and 2000 none of which corresponds in any straightforward way to surges of violence or to shifts toward economic openness in costa rica migration probabilities peaked in 1988 and then declined steadily even though most of the shift toward openness occurred after this date and violence remained flat in mexico migration probabilities held fairly steady between 1980 and 1998 despite the radical transformation of its political economy and then migration fell even as economic openness moved upward and lethal violence trended downward only in nicaragua do we observe any prima facie evidence for an association between violence and migration here peak migration to the united states clearly occurred between 1984 and 1988 a period that corresponds both to the peak of the us contra intervention and to a detectable surge in the homicide rate structural adjustment violence and migration sorting out the relationship between indicators of structural adjustment violence and international migration is difficult using graphs alone because these factors vary simultaneously over time and because migratory behavior also depends on a host of other individual and household characteristics that are unmeasured to assess more precisely how homicide openness and relative gdp affect the likelihood of migration to the united states we estimated a discretetime event history model to predict the likelihood of sending out a household member on a first trip to the united states as mentioned earlier we followed each household year by year from its inception to the survey date and noted its characteristics and national conditions with respect to openness homicide and gdp in year t 1 we then used this information to predict whether or not a member left on a first trip to the united states in year t all household years subsequent to the first recorded trip were excluded from analysis pooled model table 3 shows results for a model estimated for all four countries pooled together incorporating dummy variables to control for fixed countrylevel effects here we use two different specifications of the violence indicator raw and smoothed homicide rates the first model shows results for the raw homicide rates and finds a significant negative relationship between lethal violence and outmigration from latin american householdsas the murder rate rises the rate of outmigration falls in general then lethal violence seems to function as a deterrent rather than a stimulant to emigration with a decline in public safety apparently creating barriers to international movement the next model shows that this basic result holds for smoothed homicide rates as well both models also tell the same story about broader structural influences in the political economy the level of us contra involvement had no significant effect on outmigration across the region generally which is not surprising since it is specific to nicaragua likewise the shift toward a neoliberal economy had no effect in and of itself on the likelihood of initial migration to the united states to the extent that economic conditions matter it appears that relative income is most relevant as predicted by neoclassical theory the higher a nations gdp relative to that in the united states the lower the odds that a household will send out a member on a first us trip thus the shift from import substitution industrialization to neoliberalism appears to have had no direct effect on the likelihood of emigration at least as measured by the openness index to the extent that structural adjustment leads to outmigration it does so indirectly through its effect on a nations relative gdp and perhaps also its influence on violence as expected the effect of relative gdp is negative so that rising national income reduces emigration but contrary to the position of many observers of conditions in latin america violence seems to have a negative rather than a positive effect on the odds of initiating international movement the remaining effects in the model are generally consistent with prior research on international migration in latin america as well as with leading theoretical models the effect of age is curvilinear rising through the young adult ages before peaking and then falling at older ages as predicted by human capital theory households that already own real estate or business enterprises are less likely to send out migrants because they have no need to selffinance their acquisition through international wage labor as hypothesized by the new economics of labor migration theory given that there are few returns on education for undocumented migrants working in the united states but that education does confer benefits for social mobility at home the negative effect of education on international migration is consistent with human capital theory likewise the very strong effect of having family members in the united states is consistent with social capital theory table 3 shows that in terms of labor force status migrants from these four nations are selected disproportionately from among unskilled manual workers and are very unlikely to migrate if they are unemployedwhich is an interesting finding in itself since one would assume that unemployment would increase the likelihood to migrate not decrease it 1 as one would expect other things being equal households in the three central american nations have a lower propensity to send out 1 we estimate similar negative associations between unemployment and likelihood of migration in the individual country analyses as well migrants than do households in mexico where us migration is far more established and institutionalized mexico and costa rica given similar results for the raw and smoothed homicide rates in the pooled model we estimate the remaining countryspecific models using the smoothed rates as they are likely more reliable and less affected by random error table 4 shows the results of discretetime event history models estimated for mexico and costa rica two relatively developed and stable nations that underwent similar transition from important substitution industrialization to neoliberalism during the 1980s and 1990s but did not experience significant civil violence or armed interventions or rising homicide rates during the transition in both mexico and costa rica violence has a significant negative effect on the likelihood of outmigration to the united states acting to deter rather than instigate movement north of the border in the case of costa rica moreover the effect is strong robust and highly significant although homicide in that country is rare and varies little over time migratory decision making within households nonetheless appears to be quite sensitive to even small perturbations in the level of lethal violence over time while the direction of the effect of violence is the same in both costa rica and mexico the effect of relative gdp works in opposite directions whereas rising relative gdp lowers the odds of outmigration from mexico it raises the odds of outmigration from costa rica thus whereas structural transformation in both nations was associated with a relative deterioration in economic performance in costa rica this deterioration reduced the likelihood of international migration but in mexico structural transformation increased the odds of leaving for the united states in addition whereas the shift to economic openness had no direct effect on international migration in mexico the effect was significant and positive in the case of costa rica we also found crossnational differences in the effect of several control variables although social capital theory is vindicated in both settings by the strong and powerful effect of having family members with prior us migratory experience and whereas the unemployed are extremely unlikely to emigrate from either nation departure to the united states is more highly selective of demographic characteristics wealth and human capital in mexico than in costa rica in the former country we observe the characteristic curvilinear effect of age on the odds of international migration whereas in the latter we do not likewise possession of physical capital assets such as a business enterprise and real estate as well as human capital assets such as education substantially lowers the probability of outmigration among mexican households but not those in costa rica in sum although both costa rica and mexico underwent similar transitions to a neoliberal economic order over the past twenty years the migratory response was quite different in the two settings in mexico the structural economic transformation had no direct effect on migration but was accompanied by lagging national income that promoted migration to the united states whereas in costa rica the transformation itself had a direct effect in promoting emigration but the accompanying stagnation of income decreased rather than increased the likelihood of migration to the united states among those who did leave moreover emigrants from mexico tended to come from younger households that lacked property business enterprises and educational resources whereas emigrants from costa rican households were not selective of these characteristics the principal points of similarity concerned the effects of social capital and violence having relatives with prior us experience greatly increased the odds of outmigration from both places whereas increases in lethal violence reduced the probability of emigration to the united states in both places although households in both countries were sensitive to variations in the murder rate in neither country was structural change itself associated with any increase in lethal violence guatemala and nicaragua unlike mexico and costa rica both guatemala and nicaragua experienced violent civil wars and mass killings in addition to structural economic change during the 1980s and 1990s table 5 presents event history analyses of outmigration from these two nations in the model for nicaragua we included the index of us contra involvement developed by lundquist and massey as their earlier work showed it to be a critical determinant of outmigration from that country our preliminary analyses indicated that the contra intervention had no significant effect on emigration from guatemala or the two other countries under consideration despite extreme variations in the level of lethal violence over time in guatemala the likelihood of international migration was not significantly predicted by variations in the homicide rate nor were the odds of us emigration related to either of the politicaleconomic indicators guatemala of course experienced the least marked economic transition of the countries considered here and migration to the united states was tied more to variations in the circumstances of individual households with emigration being concentrated among younger families headed by a skilled worker who did not own a business enterprise and had immediate family members with us experience in nicaragua in contrast the likelihood of migration to the united states was quite strongly connected to macroeconomic conditions and lethal violence recall that nicaragua was the only country where the transition to neoliberalism appeared to be associated in time with declining incomes and rising violence the results shown in table 5 also reveal that in contrast to the other countries emigration is strongly and positively related to homicide rates in nicaragua even after controlling for the significant effect of the us contra intervention but the shift to openness itself had a negative rather than a positive effect on the odds of outmigration though it was relatively weak and of marginal significance statistically moreover although the likelihood of international migration evinced the expected curvilinear effect with respect to age the pattern of class selectivity was quite distinct from that prevailing in other countries among nicaraguan households those sending out migrants tended to own businesses and have welleducated spouses unemployed heads and spouses and access to migrationspecific social capital in the form of family members with us experience conclusions and implications in this article we examined the effect of structural adjustment and violence on international migration originating in four latin american countries we drew on a variety of sources to compile annual data on the homicide rate in mexico costa rica guatemala and nicaragua and on the penn world tables to measure the openness of each nations economy and its economic performance relative to the united states we then merged these annual data series with householdyear event histories constructed from the lamp and mmp and used the resulting data set to estimate a series of discretetime event history models to predict the likelihood that a household in each country sent out a family member on a first trip to the united states from 1979 to 2002 the models controlled for household traits and characteristics that prior theory and research had suggested influence the process of international outmigration including demographic circumstances asset ownership human capital resources access to social capital and labor force status both world systems theory and modernization theory posit a connection between structural economic change and violence but such a pattern held only for nicaragua where the homicide rate increased as the economy was opened to trade and average incomes deteriorated although incomes also generally deteriorated as their economies were opened up during the 1980s and 1990s the homicide rate was not correlated in time with these structural economic trends in mexico the murder rate fell slightly and in costa rica it remained fairly constant fluctuating within a narrow range guatemala experienced the slowest and least complete transition to a neoliberal economic regime and its rate of lethal violence swung markedly between extremes in response to civil conflicts rather than broader economic trends whatever the origins of violencestructural or civilthe most common effect of rising homicide was to reduce the likelihood of international outmigration as shown in figure 4 which graphs predicted probabilities of first us migration as the homicide rate ranges from its minimum to its maximum value in each country and other variables are held constant at their means in mexico and costa rica the coefficient linking the rate of lethal violence and emigration to the united states was significant and negative as it was also in the pooled model in guatemala the coefficient was negative but not statistically significant only in nicaragua was a rising homicide rate associated with a higher likelihood of outmigration to the united states and emigration from nicaragua was also characterized by a very different pattern of class selectivity being concentrated among the bourgeoisie rather than the lower classes in general the direct effect on international migration of the structural shift from import substitution industrialization to a neoliberal political economy open to trade and investment was small and insignificant figure 5 graphs predicted migration probabilities as openness moves from its minimum to its maximum within each country as can be seen the curves are relatively flat and slightly downward sloping in mexico nicaragua and guatemala the corresponding regression coefficient is significant only in the case of nicaragua and then only marginally at the 10 percent level in the pooled model moreover the effect of openness is close to zero only in costa rica is there a significant direct effect of openness and it is strongly positive other things being equal the opening of the costa rican economy to global trade and investment led to more rather than less migration to the united states the most common effect of structural adjustment on emigration was indirect through its association with declining national income but again the effect in costa rica was anomalous compared with other countries figure 6 graphs changes in predicted probabilities of us migration as relative gdp shifts from its minimum to its maximum value in each country to reveal that unlike the other cases rising gdp is associated with a sharp increase in the odds of outmigration to the united states in costa rica therefore greater economic openness and a falling income gap with the united states are associated with more international migration as shown earlier in the pooled mode of table 3 the general effect of falling national income was to increase the odds of us migration although the countryspecific models indicate that this pattern is most characteristic of mexico the sharp downward slope of the mexican curve stands out from the relatively flat curves plotted for nicaragua and guatemala whose models yield insignificant coefficients indeed the probability of outmigration from mexican households is halved moving from lowest to highest relative gdp in mexico therefore structural adjustment produced falling incomes a larger income gap with respect to its northern neighbor and more international migration as noted earlier each country has its own particular history of economic transformation and violence and our results indicate that each country also has a unique response to changes in economic openness relative income and violence costa rica is a stable democracy with relatively strong institutions welldeveloped social services and a high gdp per capita by thirdworld standards there the shift to a neoliberal economic regime did not spawn an increase in violence and in contrast to hypotheses derived by some critics of neoliberalism the increases in violence that did occur at various junctures were negatively rather than positively related to international migration moreover the direct effect of a more open economy was to encourage emigration though this positive effect was partially offset by a negative indirect effect through relative gdp as relative gdp fell in concert with greater openness it correspondingly pushed the odds of migration downward mexico also has relatively strong national institutions and is affluent by thirdworld standards and even though it has only recently made the transition to full democracy it has long been characterized by peaceful transitions of power after regular elections in this setting the shift toward neoliberalism likewise does not seem to have led to a systematic increase in the homicide rate and as in costa rica what increases we do observe are associated with less rather than more migration to the united states unlike costa rica however greater openness was not itself associated with a higher likelihood of us migration but the associated decline in relative gdp was compared with costa rica and mexico guatemala experienced more frequent and severe cycles of violence in response to civil conflicts its transition to neoliberalism was less complete and its gdp per capita was much lower here us migration was not related to either violence or structural economic conditions but rooted in household characteristics such as age property ownership occupational skill and access to social capital in the form of ties to close relatives with us experience in most countries international migration is concentrated in the lower reaches of the class distribution among those with less education less property and lower occupational status in nicaragua however emigrants to the united states came from the middle and upper classes and left in response to the economic turmoil social dislocations and violence associated first with the us contra intervention and later with the rising tide of lethal violence associated with the shift to a more open economy although the transition to neoliberalism had a small marginally significant effect in reducing the probability of emigration the accompanying rise in lethal violence acted as a stronger stimulus for the movement of middleclass families to the united states only in nicaragua did the hypothesized connection between neoliberalism violence and emigration postulated by some critics of globalization materialize thus violence appears not to have uniform effects on patterns and processes of international migration but depends on broader social and political conditions within particular countries in nicaragua where the sandinista revolution threatened bourgeois interests and led to the selective departure of middleclass migrants the rising tide of violence associated with the later shift to a more open economy motivated further outmigration by those who possessed the resources and social capital to make a move to the united states absent a progressive political revolution to threaten bourgeois interests emigration from mexico costa rica and guatemala occurred mostly among lowerclass households who lacked the resources to undertake international migration when violence increased either in response to economic restructuring or for other reasons in other words whereas greater violence acts as a stimulus to outmigration among middleclass households it acts as a barrier to international movement for poor workingclass or agrarian households economic openness and relative gdp in selected latin american nations smoothed homicide rates in selected latin american countries

the authors analyze the effects of structural adjustment and violence on international migration from selected countries in latin america by estimating a series of event history models that predicted the likelihood of initial migration to the united states as a function of the murder rate economic openness and selected controls in the country of origin although several theories posit a connection between structural economic change and violence such a pattern held only in nicaragua where the homicide rate increased as the economy was opened to trade and average incomes deteriorated moreover only in nicaragua was lethal violence positively related to outmigration in mexico costa rica and guatemala rising violence reduced the likelihood of emigration violence does not appear to have uniform effects on patterns of international migration but depends on broader social and political conditions within particular countries

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introduction according to world health organization a person aged 1019 years is considered as an adolescent 1 the transition period between the childhood and adulthood is called adolescence which is marked with the growth and development of the child during this period physical psychological and biological development of the child occurs 2 it is recognized as a special period in a girls life cycle which requires special attention menarche is an important biological milestone in a womans life as it marks the onset of the reproductive phase of her life the average age at menarche is mostly consistent across the populations that is between 12 and 13 years of age 34 unfortunately due to lack of knowledge on menstruation preparedness and management or due to shyness and embarrassment the situation becomes worse for girls 5 menstruation is a natural process but it is still a taboo in indian society as it is considered unclean and dirty 6 menstruation wastes are the wastes that are generated by a female in her reproductive years these wastes are produced during menstruation commonly known as menses periods or monthly bleeding cycle 7 the menstrual cycle has three phases that is follicular phase ovulation phase and luteal phase menstruation is regulated by hormones in this process endometrium lining of uterus gradually thickens and sheds off and causes bleeding that normally last for 35 days and occasionally up to 7 days menstruation sheds twothirds of the endometrial lining in addition to blood menstrual fluid contains mucus and vaginal secretions 8 the menstrual flow varies from female to female and may be more or less at the beginning of menses or may change throughout the cycle the color of the menstrual fluid varies between red bright red and dark brown to black menstrual fluid may or may not have unpleasant odour especially when it comes in contact with air menstrual flow or duration also changes before menopause or during gynaecological cancers under conditions of hormonal imbalance fibroids polyps and endometriosis menstrual flow increase and excessive loss of blood through menstruation can lead to anaemia women have developed their own personal strategies to handle this period of time globally these strategies vary greatly due to the personal preferences availability of resources economic status cultural traditions and beliefs education status and knowledge about menstruation practices related to menstruation hygiene are of major concern as it has a health impact if neglected it leads to toxic shock syndrome reproductive tract infections and other vaginal diseases 9 10 11 poor genital hygiene negatively affects adolescents health most girls are unaware and unprepared for menarche as they are not informed or illinformed about menstruation 12 the main objective of this review was to summarize the concern and possible methods of menstrual waste management in lowincome countries the review article was aimed at understanding the menstrual practices product design demands and disposal strategies it includes both a summary of the existing menstrual hygiene needs and management and also an analysis of the current knowledge in the fields of public health water and sanitation and solid waste management cultural beliefs and restrictions during menstruation menstrual hygiene practices were affected by cultural norms parental influence personal preferences economic status and socioeconomic pressures menstrual beliefs refer to misconceptions and attitudes towards menstruation within a given culture or religion menstrual beliefs knowledge and practices were all interrelated to the menstrual hygiene management 1314 by reviewing literature and articles published in journals and reports available on the internet we found many cultural and religious beliefs followed by people regarding menstruation these norms were the barriers in the path of good menstrual hygiene practices many women experiencing restrictions on cooking work activities sexual intercourse bathing worshipping and eating certain foods 15 these restrictions were due to the overall perception of the people regarding menstruation as they consider it dirty and polluting 16 in some parts of the country there were restrictions on bathing and a taboo against burial of bloodied menstrual cloth cloths should first be washed and then buried or reused washing and drying thought to be done secretly or in a hidden corner so that it cannot be seen by others 17 it was also believed that menstrual fluids may be misused for black magic so women should wash the wrappercloth wore during menses only at night when others were asleep 18 menstrual flow was seen as dirty polluting and shameful so women hide menstrual cloths for fear of being cursed in similar findings it was believed that menstrual waste was linked to witchcraft and danger so it must be buried unless witches go after human blood and find the menstrual wrappercloth and destroy the women by causing infertility 13 from all these beliefs it was clear that education plays a key role in menstruation hygiene management by educating both men and women regarding menstruation we can overcome these false beliefs and taboos due to cultural expectations and restrictions many girls were not adequately informed about the realities of menstruation as a result they feel subnormal diseased or traumatized 19 unprepared girls were frightened confused and feel embarrassed by menarche likely to develop negative attitudes towards menstruation 20 even touching of menstruating women was considered toxic they were prohibited from cooking and from taking certain foods like pickle these prohibitions are more in the rural areas than in the urban areas they were also not allowed to participate in religious activities or to contact religious articles 21 menstruating girls are also not allowed to bath and wash hair as it is believed to impede blood flow types of absorbents used during menstruation the preference of sanitary protection material is based on personal choice cultural acceptability economic status and availability in local market along with basic sanitation facilities one should be also provided with soap and menstrual absorbents to manage menstruation hygiene the choice of absorbents varies among rural and urban women and girls in rural areas the most preferred absorbents are reusable cloth pads and in urban areas women prefer to use commercial sanitary pads chlorinebleached kraft or sulphate pulp is used by manufacturers to produce fluff pulp as absorbent used to make disposable sanitary products nowadays many deodorised and nondeodorised sanitary products are available in the market made of synthetic fibre rayon these deodorised products contain chemicals like organochlorines which have antibacterial activity due to their chemical composition these products when buried in the soil they kill the soils microflora and delay the process of decomposition 22 different menstrual products used by womengirls are discussed below reusable and washable cloth pads they may be sustainable sanitary option but must be hygienically washed and dried in the sunlight the suns heat is a natural sterilizer and drying the clothscloth pads under it sterilizes them for future use these cloth pads are reusable so they are costeffective easily available and ecofriendly they also need to be stored in a clean dry place for reuse to avoid contamination commercial sanitary pads they are easily available at many stores chemist shops or online they are expensive compared to cloth pads nonreusable and not very environmentfriendly the cotton used in their making is not 100 natural and may contain pesticides tampons they are the type of absorbent that provides internal protection they are kind of plug of soft material which is inserted into the vagina to absorb the menstrual flow before it leaves the body they are expensive not easily degradable in nature and hence not very environmental friendly nowadays sea sponge tampons are available in the market which are a natural alternative to synthetic tampons reusable tampons these are washable tampons made up of natural materials like bamboo wool cotton or hemp they are also knitted or crocheted using the natural absorbent material like cotton or wool they are inserted into the vagina to absorb menstrual flow same as the disposable tampons menstrual cups they may be a new technology for poor women and girls and an alternative to sanitary pads and tampons they are like cups made of medical grade silicone rubber which makes the cup easy to fold and get inserted into the vagina to collect menstrual blood they can be worn up to 612 hours depending upon the amount of menstrual flow so it needs to be removed and emptied less frequently they are reusable and environmentfriendly it offers sustainable practical and costeffective alternative where sanitation conditions are not good 36 bamboo fibre pads instead of wood pulp bamboo pulp is used as an absorbing material in these sanitary pads it has more absorbing capacity and is safer to use they are affordable easily decomposed and environmentfriendly pads which also possess antibacterial properties this provides infection and irritationfree menstruation also bamboo charcoal pads are available in the market with advantage that blood stains are not clearly visible and are also reusable in nature 37 banana fibre pads nowadays lowcost sanitary pads for rural women made from waste banana tree fibre were sold under trade name saathi in india they are environmentfriendly and decompose within six months after use besides these products women in the remote rural areas also use natural materials like cow dung leaves and mud 38 water hyacinth pads menstrual pads manufactured using water hyacinth is sold under trade name jani they are costeffective easily biodegradable and ecofriendly in nature menstrual waste disposal techniques used by women appropriate disposal of used menstrual material is still lacking in many countries of the world most of the countries have developed techniques to manage their fecal and urinary wastes but because of lack of menstrual management practices in the world most of the women dispose of their sanitary pads or other menstrual articles into domestic solid wastes or garbage bins that ultimately become a part of solid wastes toilet facilities in india lack bins for the disposal of sanitary pads and hand washing facilities for menstruating women to handle menstrual hygiene in urban areas where modern disposable menstrual products are used they dispose of them by flushing in toilets and throwing in dustbins or through solid waste management 23 but in rural areas there are many options for disposing menstrual waste such as by burying burning and throwing in garbage or in pit latrines in rural areas mostly women use reusable and noncommercial sanitary materials like reusable pads or cloths thus they generate lesser amount of menstrual waste as compared to women in urban areas who rely on commercial disposable pads the menstrual material was disposed of according to the type of product used cultural beliefs and location of disposal in slum areas women dispose their menstrual waste into pit latrines as burning and burial were difficult due to limited privacy space 24 the reason behind that is it was seen by men or used in witchcraft in schools due to lack of sanitary facilities girls throw their pads in toilets in some cases girls threw away their used menstrual clothes without washing them also many were reported being absent from school due to lack of disposal system broken lockdoors of toilets lack of water tap bucket and poor water supply 2526 in some schools incinerators or feminine hygiene bins are used for disposing menstrual waste material but due to shyness or fear of being seen by others they refrained from using it 27 the behavior of women regarding disposal is different when being at home and away from home at home they dispose the waste by wrapping and throwing in the dustbin along with other domestic waste as mentioned above the disposing habits change according to the place in public places prior to having knowledge about the consequences of flushing the pads they flush them in the toilets or wrap and throw them in the dustbins where dustbins are not placed they leave the soiled pads wrapped or unwrapped in the toilet corners this makes the toilets dirty breeding place for flies and mosquitoes and also unhygienic for other toilet users and cleaners in many cities the persons who manage the public toilets always complain of blockage of sewage system because of flushing of sanitary pads or rags in the toilet consequences of menstrual waste disposal as sanitation systems were designed with urine and feces in mind they are unable to cope with the menstrual absorption materials these absorption materials clog the sewer pipelines as they are unable to pass through and cause the system backflow 28 materials like tampons cotton wool toilet paper and other organic materials used for menstrual management might be decomposed in pit latrineslandfills except the plastic inlay of the commercial sanitary pads sanitary napkins might decompose over a period of about one year except its plastic lining in onsite sanitation 29 in rural areas pit latrines once full they were covered with soil and new pit was dug but due to space limitations this was not practiced in urban areas 30 it was reported that some women and girls wrap their used menstrual cloths and packs in polythene bags before disposing in pit latrines which prevents them from decomposition nowadays mostly womengirls prefer commercial sanitary pads and tampons which are made up of superabsorptive materials like polyacrylate these pads and tampons when flushed in the toilets they get saturated with liquid and swell up thus resulting in sewage backflow a serious health hazard the adhesive wings and the perforated plastic layers in the commercial sanitary napkins are not easily biodegradable the sewage blockages were mostly due to accumulation of excessive quantity of solid waste or sand which results in hardening of the sludge in the pits blockage of sewage system is a global problem and major contributing factor is flushing of menstrual products in toilets deodorised sanitary products used by womengirls contain chemicals used in bleaching such as organochlorines which when buried in the soil disturb the soil microflora and decomposition takes time 22 people living alongside river banks throw menstrual waste into water bodies which contaminate them these materials soaked with blood were breeding places for germs and pathogenic microbes 31 sanitary products soaked with blood of an infected womengirl may contain hepatitis and hiv viruses which retain their infectivity in soil and live up to six months in soil the clogged drainage with napkins has to be unblocked and cleaned manually by conservancy workers with their bare hands without proper protection and tools this exposes the workers to harmful chemicals and pathogens incineration is a better technique to dispose of menstrual waste but burning of pads releases harmful gasses that effects health and environment burning of inorganic material at low temperature releases dioxins which are toxic and carcinogenic in nature role of menboys towards menstrual hygiene management one of the main reasons why menstruation is a taboo and menstruation hygiene is neglected is gender inequality unequal rights given to men and women result in womens voices being ignored within households and communities and in development programmes due to cultural norms and stigmas menstruating women are not allowed to use water and sanitation facilities and in some cases even excluded from home as menstruation is considered impure 3233 therefore comprehensive programmes that engage both men and women should be organized related to menstrual hygiene men can support and influence women and girls in managing menstruation in households schools work and community through many roles as husbands fathers brothers students teachers colleagues leaders and policymakers by reviewing literature it was found that at household level men do not support women regarding menstruation hygiene and never have they discussed menstrual issues with their wives and daughters as they are decisionmakers at household level in many cases they do not give money to buy menstrual products such as commercial sanitary pads tampons and menstrual cups as they consider it money wastage so women have to rely on cheap reusable cloth pads which they have to wash dry and use again in other cases due to low family income men hesitate to give money for such costly products so in both cases women have to compromise with their menstrual needs and personal hygiene 34 decisions related to constructing toilets in houses are also taken by male members so it is a big barrier in menstrual hygiene as women find it difficult in cleaning and changing menstrual materials in privacy 35 women and girls who have toilets at home feel shy and embarrassed as the drain that leads out is not covered and there is a chance of seeing blood flowing in drain by others 3637 in some reports it was found that parents did not allow boys to discuss such topic as they were not important for their future so the boys received information about menstruation from friends and internet which is inaccurate and incomplete in some places like in nepal menstruating women have to live separately in a chhaupadi during menstruation outside the house this cultural norm is supported by both men and women making it difficult to survive for a menstruating womengirl during winters 38 they also have to face many challenges living in chhaupadis such as getting bitten by snakes fires and rapes most men do not know about the menstruation and physiological changes in women during menstruation and menstrual cycle so it is difficult to change their perception regarding menstruation and menstrual hygiene due to unwillingness myths prejudices and misconceptions it is difficult to talk about menstruation with men and boys but by engaging them into group discussions and regular community meetings we can change their perception and make them aware about their role regarding menstrual hygiene management in india a man named arunachalam muruganantham known as indias menstrual man develops an inexpensive and environmentfriendly machine which produces semibiodegradable sanitary pads men can help women and girls by constructing toilets incinerators and latrines with chutes at homes and schools and at community level at household level they help by providing toilet facilities with privacy water and soap and by giving them money for menstrual products as the decisionmaking power is in mens hand making household budgeting for sanitary materials supports and empowers women by allowing them to move freely with lower risk of stains men who are in politics support menstrual hygiene management by making girlswomen friendly policies by providing sanitary materials free of cost or at affordable prices by providing water and sanitation in their areas and by conducting seminars and workshops in rural areas role of teachers in creating awareness regarding menstruation and menstrual waste management in schools teachers can make the school environment girlwomen friendly to manage menstruation with dignity sex education in schools helps adolescents to discover their sexual identity to protect themselves from sexual abuse unwanted pregnancies and sexually transmitted diseases and to know physiological changes occurring in the body and how to take care of personal hygiene 39 in most of the cases teachers attitude is not good and supportive towards menstruating girls in schools different views of parents teachers and society affect sex education being taught in schools and colleges cultural religious and social barriers also create hindrance in the path of sex education 40 our education sector plays an important role in childs growth and development by allowing them to respond to changes and challenges they are facing in daytoday life 41 but many times it avoids issues related to the menstruation and menstrual hygiene management by considering it ones personal matter and should be discussed within the house menstruation is a silent issue in girls life which is further affected by teachers attitude school environment and infrastructure because of this many girls remain absent from schools during this time sex education is often neglected from the school curriculum which negatively impacts the students life they get information about puberty sexual intercourse menstruation and other physiological changes in ones body from books friends and internet which may be incomplete or inaccurate due to lack of knowledge and social interaction teasing and taunting with hurtful nicknames are common in schools this makes it difficult for a girl student to survive in this environment so they remain absent from school in many schools both male and female teachers are not ready to discuss menstruation and menstrual hygiene management with students the female teachers are also not available in many schools teachers often skip such topics in books as they do not want any open discussion in the class or to escape from the questions asked by students teachers also feel shy and embarrassed to discuss such topics in class due to language barrier 42 in most schools english is not a compulsory subject so teachers have to discuss them in local language and using vernacular words in front of students is an embarrassing thing due to unsupportive environment in the schools it was also found that some girls hesitate to stand to answer teachers questions in fear of leakage or smell and also hesitate to write on blackboard in fear of any menstrual accident and blood stains on clothes seeing by others in some reported cases parents do not allow girls to go to schools upon reaching puberty in fear of sexual harassment by boys and male teachers in schools 43 to overcome these issues male teachers and employees in the schools and institutes should be well educated and confident regarding menstruation and menstrual hygiene management so that they support girlswomen by providing safe environment and privacy a committee of teachers including both male and females should be made in the schools to collect funds for providing sanitary napkins soaps water and toilet facilities in schools so that girls manage their menstruation with ease and safety committee should also provide dustbins for menstrual waste disposal separate toilets for girls and boys with proper doors and locks should be built in the schools teachers should educate girls about menstrual health management and its link to their health they should also make girl students aware of how to dispose of used menstrual products at home and in schools and about the consequences of throwing them in open or flushing them in toilets open discussions on puberty sex education menstruation and so forth should be organized by schools in every class to make students aware this will solve their unsolved queries by providing them correct knowledge promote social interaction and also develop a trust relationship with fellow friends and teachers schoollevel health policies should be made by school management committee to promote and educate students regarding health and safety to ensure adequate water and sanitation facilities and to protect girl students and staff from bullying and sexual harassment some case studies case 1 recently in a school in tamil nadu a 12yearold school girl of 7th class committed suicide after menstrual shaming according to her mother her periods started during a class where she was given a duster cloth to be used as a pad then reportedly she was forced to leave the classroom when her clothes got stained by blood the next day she did not bear the humiliation and committed suicide due to harassing and torturing by the teacher in the class as written in the suicide note case 2 around 70 girls of the kasturba school hostel were ordered to remove their clothes by the hostel warden to check for menstrual blood after she found blood stains in the washroom this shameful act happened in muzaffarnagar in march 2017 strategies for the management of menstrual waste disposal of menstrual waste is of major concern as it affects health and environment there is a need for effective menstrual materials which needs less and costeffective management companies dealing with manufacturing of sanitary pads or other articles should disclose the information on the pads regarding the chemical composition of the pads so that appropriate technologies could be used for their disposal and treatment environmentfriendly chemicals should be used by manufacturers of sanitary products to stop soil and water pollution and to fasten the decomposition process guidance regarding menstrual management to adolescent girls and women is a much needed step menstrual hygiene management should be an integral part of education curriculum distribution of menstrual products should be free of cost in schools and educational institutes 44 recently instead of subsidizing the menstrual pads indian government has imposed 12 gst on them which is not very women friendly the toilets must be designed and built to be girl women friendly 45 in kerala some schools have installed sanitary napkin vending machines in toilets which are semiautomatic and operate by inserting a coin in it it contains 3050 sanitary napkins to meet the emergency needs of the girlswomen in schools there should be a separate collection system for the menstrual wastes without affecting the privacy and dignity of women specific sanitary dispensers to collect menstrual waste should be installed there should be sufficient space for washing cleaning private parts and hands and for changing or dealing with stained clothes to fulfil these requirements there must be water availability toilet paper dustbin and a sink to wash menstrual products dustbins should be covered by lid and emptied from time to time to keep the toilets clean from flies mosquitoes and bad odour covered containers and dustbins have advantage of hiding the waste being seen by others they are installed in a place that offers privacy 21 gloves and proper safety tools should be provided to the cleaners so that they are not exposed to pathogenic organisms and harmful gasses government should introduce new rules for the safe disposal and treatment of menstrual wastes as they are a welcomed step in menstrual hygiene management a lady named swati designed this incinerator and named it ashudhinashak which burns many sanitary napkins at a time without creating any smoke this ecofriendly and cheap innovation is appreciated by rural women who found difficulty in disposing them 96 better disposal techniques special covered bins should be installed to handle menstrual waste disposal bags should be provided by manufacturing companies with color indication for disposing these products these bags should be freely distributed among schools and institutions menstrual waste should not be disposed of along with domestic waste pads should be properly wrapped in newspaper and then thrown in the dustbins by this it should also be safe for rag pickers as it does not expose them to any diseasecausing pathogens conclusions menstrual hygiene should be promoted by implementing a course on menstruation and menstrual hygiene management teachers should be educated and trained to impart knowledge about menstruation and menstrual hygiene management among students social and electronic media also play an important role to make the girls and women aware about the latest menstrual products different manufacturers government policies and so forth subsidies should be given on menstrual products so that every girlwomen can afford them easily nongovernment organizations should come forward to educate rural people about menstruation menstrual hygiene management importance of toilets at homes hand washing diseases related to reproductive tract due to poor hygiene and so forth emphases should be given on the use of reusable sanitary or cloth pads to overcome the problem of disposal girls and women should be aware of the consequences of disposing used menstrual products in open or flushing them in toilets dustbins with proper lids should be placed in the toilets if possible incinerators should be installed at homes schools and community levels this study reveals that lack of privacy is a major concern both in household and in schools also ignorance misconceptions unsafe practices and illiteracy of the mother and child regarding menstruation are the root causes of many problems so there is a big need to encourage adolescents at school levels to practice safe and hygienic behaviors conflicts of interest the authors of this paper have no conflicts of interest stem cells international hindawi

menstruation and menstrual practices still face many social cultural and religious restrictions which are a big barrier in the path of menstrual hygiene management in many parts of the country especially in rural areas girls are not prepared and aware about menstruation so they face many difficulties and challenges at home schools and work places while reviewing literature we found that little inaccurate or incomplete knowledge about menstruation is a great hindrance in the path of personal and menstrual hygiene management girls and women have very less or no knowledge about reproductive tract infections caused due to ignorance of personal hygiene during menstruation time in rural areas women do not have access to sanitary products or they know very little about the types and method of using them or are unable to afford such products due to high cost so they mostly rely on reusable cloth pads which they wash and use again needs and requirements of the adolescent girls and women are ignored despite the fact that there are major developments in the area of water and sanitation women manage menstruation differently when they are at home or outside at homes they dispose of menstrual products in domestic wastes and in public toilets and they flush them in the toilets without knowing the consequences of choking so there should be a need to educate and make them aware about the environmental pollution and health hazards associated with them implementation of modern techniques like incineration can help to reduce the waste also awareness should be created to emphasize the use of reusable sanitary products or the natural sanitary products made from materials like banana fibre bamboo fibre sea sponges water hyacinth and so on

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background over the past four decades global prevalence of childhood obesity has increased 10fold 1 predictions forecast that if current trends continue by 2030 60 of the global adult population will be overweight or obese 2 given that obesity in childhood is associated with premature mortality and physical morbidity in adulthood 3 tackling childhood obesity is increasingly a public health priority for governments 4 of increasing concern are widening inequalities in obesity prevalence by age 11 uk children from lower income families are three times as likely to be obese than their more advantaged counterparts 5 these differences progressively worsen with age fuelling inequality in health across the life course 6 7 there are also stark ethnic and racial differences in childhood adiposity with higher rates of obesity within certain ethnic minorities including black british and bangladeshi 8 9 it is suggested that these differences are partially linked to existing disparities in socioeconomic resources between ethnic groups 9 at present there is limited understanding of the modifiable factors driving strengths and limitations of this study ► this is the first study to investigate socioeconomic and ethnicityrelated differences in childrens vigorous intensity physical activity behaviour accounting for moderate physical activity ► we used data from the millennium cohort study which used a stratified sampling design enabling adequate representation of socioeconomically disadvantaged and ethnic minority children ► this is the largest available accelerometer dataset of objectively measured physical activity in uk children ► boys certain ethnic minorities and children living with only one parent were less likely to provide valid accelerometer data which may have affected the representativeness of our findings ► the accelerometer measurements utilised are limited in their ability to classify behaviour detect certain activities upper body movements or changes in terrain open access socioeconomic and ethnicityrelated disparities in childhood obesity physical activity is a key behavioural driver of cardiovascular disease risk in children 10 evidence of an association with obesity is less clear 11 12 however consistent evidence suggests that vigorous physical activity is more strongly associated with reduced waist circumference and adiposity relative to lower intensity activity including moderate physical activity 13 14 15 16 17 previous research using objectively measured physical activity has demonstrated no socioeconomic patterning in childrens adherence to the international guidelines to engage in moderatetovigorous intensity activity for at least 60 minday 18 19 20 while there is some evidence of ethnic differences in activity levels 21 these analyses are confined to the use of aggregated mvpa to quantify activity levels this focus on mvpa may be why physical activity only explains a small portion of the socioeconomic gradient in overweight risk present within uk children 22 the importance of intensity specific differences of mvpa in explaining socioeconomic and ethnic inequalities in health remains underexplored considering that moderate physical activity and vigorous physical activity are accumulated through different types of activities 23 they may be differently distributed in population subgroups in highincome countries including the uk childrens participation in the organised sports activities that drive vpa have been shown to be socially patterned due to unequal access support and costs 24 25 26 children from certain ethnic minorities have been shown to face additional barriers to sport participation due to cultural and religious factors lack of access and parental safety concerns 27 the need for understanding of these intensity differences is strengthened by evidence suggesting that the agerelated decreases in vpa observed annually into adulthood are more pronounced in black and socioeconomically deprived children than their counterparts 28 we propose that socioeconomic and ethnic differences in childrens higher activity intensity could help to explain wellestablished socioeconomic and ethnic gradients in obesity thus the objective of this study was to investigate if daily vpa adjusted for minutes of mpa performed differs by socioeconomic position or ethnicity in a large sample of uk children aged 7 years methods sample this analysis used data from the millennium cohort study a nationally representative longitudinal study of children born in the uk between september 2000 and january 2002 29 mcs was developed to track the social economic and health experiences facing children born at the start of the 21st century the original cohort included 18 818 children data were first collected when cohort participants were 9 months old through a homebased interview subsequent followup interviews at ages 3 5 7 and 11 years were conducted in the home environment with the main respondent 30 at age 7 an accelerometer study was conducted with participants parental consent and child assent were obtained for participation in the accelerometer study to ensure adequate representation of all four uk countries including disadvantaged and minority populations a stratified clustered sampling design was used to oversample children living in wales scotland and northern ireland disadvantaged areas and communities with high proportions of minority ethnic groups the mcs received ethics approval from the south west and london multicentre research ethnics committees uk and the yorkshire research ethics committee the analyses presented here used data from followup 4 at age 7 years patient and public involvement this analysis is of secondary data collected a decade ago and accordingly the participants included were not involved in the conceptualisation or design of our specific study physical activity at mcs4 participating children were invited to participate in an accelerometer study consenting children were sent a preprogrammed actigraph gt1m accelerometer set to record data at 15 s epochs all data collection and processing was performed inhouse according to predetermined criteria 31 actigraph accelerometers have been shown to be reliable and valid in comparison to measures of physical activity derived from heart rate monitoring indirect and room calorimetry and doubly labelled water 32 33 34 children were instructed to wear the accelerometer on an elastic belt around their waist for 7 days throughout all waking hours and to return it by post children were additionally asked to complete a monitor wear log to help identify nonwear time data were collected over a 15month period between may 2008 and august 2009 data were downloaded using actigraph v383 and processed according to predetermined criteria using the r statistical package pawacc 31 nonwear time defined as 20 min or more of consecutive zero activity counts were excluded from the analysis counts were separated into sedentary moderate and vigorous categories 31 to ensure reliable estimates of activity the sample was restricted to participants with three valid days of data 35 the sample was additionally restricted to singleton children extreme values above a threshold of ≥11 715 cpm were excluded as this may indicate a faulty monitor open access sociodemographic variables considering strong evidence that health and obesity is patterned strongly and independently along both socioeconomic 36 37 38 and ethnic 39 40 lines our analysis examines the association with both indicators information pertaining to socioeconomic position and ethnicity were collected at mcs4 socioeconomic position was measured using maternal education and equivalised household income maternal education captures the socioeconomic circumstances that accrue to a child and is advantageous as it can be applied to mothers irrespective of whether or not they are in paid employment at the time of interview 41 maternal education was categorised into five groups none low medium high and higher 42 annual household income was equivalised for household composition based on guidance from the organisation for economic cooperation and development 29 ethnicity was parentreported and categorised in our analyses as white any mixed indian pakistani or bangladeshi black or black british or other parents were asked to select from a longer list which ethnic group they identify most with the ethnic classifications utilised were based on census categories in accordance with guidelines from the office for national statistics 43 statistical analysis multivariable linear regression models were fitted to analyse differences in absolute mean daily minutes of vpa achieved across socioeconomic and ethnic groups adjusting for mean daily minutes of mpa mean accelerometer wear time season of measurement age and sex separate models were run for each exposure variable to assess the effects of each seperately 44 models were also run separately for week and weekend days as there is evidence that children accumulate physical activity differently on weekdays and weekend days 45 further it is possible that different socioeconomic and ethnic subgroups of children engage in different types of activities with distinct weekly patterning all model residuals were assessed for normality to investigate effect modification by gender interactions were run across all models in sensitivity analyses additional adjustments for body mass index were explored all analyses were conducted using stata v151 software with survey commands used to account for the stratified clustered design of mcs and to obtain robust standard errors 46 47 sampling weights adjusted for unit nonresponse between waves were utilised to support the premise of the current analyses that vpa is most strongly associated with adiposity additional linear regression models were fitted to study differences in bmiz score by mean daily minutes of vpa and mpa separately adjusting for accelerometer wear time age and sex results of the 12 872 children that consented to the accelerometer study 9772 returned the accelerometers with a final sample of 6497 children following inhouse processing by mcs 48 application of our study inclusion criteria resulted in an analytic sample of 5172 children this drop was predominately driven by our requirement participants three or more valid days include one weekend day to enable comparisons across weekend and weekdays on average children in the weighted sample were 68 years of age and 50 female overall 144 of girls and 117 of boys were overweight while 41 and 35 were obese these classifications were open access made through application of the who growth standards to produce age and gender specific zscores utilising stata functions zanthro and zbmicat 49 the sample included children from each country across the uk sociodemographic and physical activity summary characteristics of the analytic sample are outlined in tables 1 and 2 respectively these two tables of sample characteristics are based on the weighted sample given that all our analyses are weighted dropout analyses showed that those participants included in the analytic sample were more likely to come from a higher income household have mothers with higher levels of education and be male when compared with participants who provided accelerometer data but did not meet the criteria for the analytic sample multivariable linear regression models revealed significant differences in the minutes of daily vpa accumulated across socioeconomic subgroups significantly more minutes of daily vpa was accumulated in each level of maternal education compared with those whose mother indicated no qualifications this relationship was more pronounced on weekdays than on weekend days analyses by equivalised household income supported this indicating significantly more time spent in vpa with increasing household income figure 1 illustrates this effect and shows the proportion of vpa within daily mvpa by categories of activity stratified into tertiles of equivalised household income this demonstrates that irrespective of activity level children from higher affluence families generally accumulate a greater proportion of their daily mvpa from vpa pakistani and bangladeshi children performed on average over 3 min less daily vpa in comparison to white british children overall on weekdays and weekend days this difference was slightly more pronounced on weekdays versus weekend days children from other ethnic groups also accumulated less daily vpa overall and on weekdays in contrast children from a mixed ethnic descent accumulated comparatively more minutes of vpa daily across the week and on weekdays but not weekend days there were no significant interactions with gender in any model additional adjustments for bmi zscore did not change the pattern of results supporting multivariable linear regression models for bmi zscore revealed a significant association between daily minutes of vpa and bmi zscore with a 1 min difference in vpa associated with 0012 lower bmi zscore the association of daily mpa with bmi zscore was statistically significant but substantially smaller discussion this study reveals clear socioeconomic and ethnic differences in childrens time spent in vpa children from less affluent backgrounds alongside those from certain minority ethnic groups accumulated less of their daily activity from vigorous intensity activities these differences were consistent in both boys and girls and mirror existing inequalities in childhood adiposity 50 although the effect sizes are relatively small and possibly not clinically relevant at an individual level we suggest that these differences are relevant at a population level and changes to reduce existing gaps in vpa could have populationlevel implications for inequalities in adiposity in uk children 10 to our knowledge this is the first study to investigate socioeconomic and ethnicityrelated differences in the patterning of childrens vpa accounting for time spent in mpa while prior studies have investigated activity intensity 51 these did not account for mpa or have the capacity to investigate subgroups due to sample homogeneity accounting for mpa when analysing vpa is critical given differences in the accumulation and distribution of overall activity across individuals mcs offers the largest available representative accelerometer dataset of uk children from all four countries the objective measurement of free living activity using accelerometers is critical when comparing subgroups of children 52 as selfreported data are likely to be differentially biased across these subgroups 53 an additional strength of the cohort comes from the stratified sampling design which enabled adequate representation of socioeconomically disadvantaged and ethnic minority children this is further enhanced by the comprehensive sociodemographic information linked through parent interviews much previous evidence relies on childreported assessment of open access socioeconomic position resulting in substantial missing or invalid data with higher rates of nonresponse from socioeconomically deprived children 54 like any birth cohort representativeness of the mcs sample is affected by participant attrition between waves of assessment prior analyses of mcs have demonstrated that boys certain ethnic minorities and children living with only one parent were less likely to provide valid accelerometer data 55 dropout analyses showed that the participants included in this analysis were more likely to be male and come from a higher socioeconomic background it has previously been shown that the presence of a missingnotatrandom mechanism that underestimates the volume of physical activity during weekend days in this cohort 56 this mechanism may have influenced our findings the findings of our models need to be interpreted in consideration of these limitations and our inclusion criteria specifically our restriction to participants with at least 10 hours of wear time across 3 days finally accelerometers underestimate activity involving vertical movement and those for which the accelerometer was not to be worn if these behaviours are also socioeconomically or ethnically patterned this may have led to an under or overestimation of the true associations our supplementary analyses support the wellestablished notion that vpa is more strongly associated with open access bmi zscore than mpa 13 1517 and point to a relevant effect size at a population level 10 there are multiple reasons why the differences in vpa observed may exist due to unequal access and costs the organised contexts through which children accumulate vpa have been shown to result in differences in participation between more and less advantaged subgroups of children 24 25 26 these findings are however based on questionnairebased assessments which capture sports and organised activity more accurately than other types of activity 57 additional factors including parental perceptions of time commitments and the limited variety of activities accessible are significant factors linked to low levels of vigorous physical activity in low income families 58 furthermore differences in home and family support for physical activity have been demonstrated between ethnic groups 27 for instance the presence of cultural and religious barriers have been found to impede participation in organised activity among pakistani and bangladeshi children who in this analysis had the lowest levels of vpa our findings also demonstrate that differences in vpa between children from high and low maternal education families are more pronounced during the week this may result from factors such as longer inconsistent work hours within lowincome jobs these differences and differential barriers should be considered when developing interventions to increase vpa and potentially impact obesity prevalence in all groups furthermore this finding highlights the potential of schoolbased and afterschool sports clubs to contribute to a solution for reducing existing behavioural inequalities despite known differences in boys and girls mvpa 59 60 also in this cohort 21 the lack of gender interaction in this analysis reveal that both girls and boys participation in vpa are equally affected by socioeconomic and ethnic factors international physical activity guidelines for children focus on mvpa in part because increases in mvpa are hypothesised to be easier to achieve than vpa at a population level 61 our findings indicate that by utilising the aggregate measure of mvpa we may be overlooking significant differences in the relative participation in mpa and vpa between population subgroups and tolerating substantial inequalities in the most important segment of physical activity for health outcomes uk activity guidelines additionally recommend that children minimise the amount of time spent being sedentary for extended periods and that vigorous intensity activities be incorporated at least three times a week our results provide further empirical evidence to support the findings of richards et al 62 and their accompanying call to place more attention on the vpa component of guidelines to ensure health benefits further evidence suggests that childhood participation in sporting activities is vital to the development of fundamental motor skills which strongly predict physical activity and weight status both in childhood and throughout adulthood 63 to lay a foundation for lifelong activity participation it is critical that children especially those from disadvantaged backgrounds are provided with sufficient opportunities to develop fundamental motor skills however there is currently insufficient evidence concerning the most appropriate daily dose of vpa and how to effectively promote vpa across population subgroups research efforts are needed to develop effective interventions for increasing vpa conclusion we found that the amount of vigorous intensity activity accumulated was socioeconomically and ethnically patterned in 7yearold uk children mirroring known inequalities in adiposity 50 these findings suggest that the current central focus of physical activity guidelines and accordingly interventions on the promotion of aggregate measures of mvpa may be masking behavioural differences that may have an influential role in widening inequalities in obesity between more and less advantaged subgroups in efforts to combat rising and widening childhood obesity rates our results suggest a need for a greater focus on the promotion of vpa in health promotion efforts particularly for those children from more disadvantaged backgrounds open access to thank stephen sharp at the mrc epidemiology unit for his statistical insights and input on the models contributors rl and evs designed the study ja and aa provided inputs on preliminary results and contributed to redeveloping the statistical models rl conducted all of the analyses and drafted the manuscript all authors contributed to the interpretation of the results and critically reviewed the manuscript all authors read and approved the final manuscript rl is the guarantor and responsible for the overall content competing interests none declared provenance and peer review not commissioned externally peer reviewed data sharing statement this is a secondary data analysis based on the millennium cohort study data the data and access policy are available online here beta ukdataservice ac uk datacatalogue series series id 2000031 access open access this is an open access article distributed in accordance with the creative commons attribution 40 unported license which permits others to copy redistribute remix transform and build upon this work for any purpose provided the original work is properly cited a link to the licence is given and indication of whether changes were made see creativecommons org licenses by 4 0 references

objective to investigate if daily vigorous physical activity vpa adjusted for minutes of moderate physical activity mpa performed differs by socioeconomic position or ethnicity in a large sample of uk children with objectively measured physical activity design nationally representative prospective cohort study setting uk children born between 2000 and 2002 participants 5172 children aged 78 with valid accelerometer data for ≥10 hour on ≥3 days including 1 weekend day main outcome measures time spent in vpa 3841 counts per min explanatory measures maternal education annual household organisation for economic cooperation and development equivalised income ethnicity results multivariable linear regression models fitted to explore differences in average daily minutes of vpa adjusted for mpa mean accelerometer wear time season of measurement age and sex revealed significantly higher amounts of vpa accumulated as a childs socioeconomic position increased highest vs lowest level of maternal education β 296 p 000 annual household equivalised income β 058 p 000 per £10 000 annual increase additionally children from certain minority ethnicities bangladeshi and pakistani β 334 p 000 other ethnic groups β227 p 002 accrued less daily vpa compared with their white british counterparts conclusions the socioeconomic and ethnic patterning of vigorous activity observed in this study mirrors parallel inequalities in rates of childhood obesity given the stronger association of vpa with adiposity than of mpa intensity specific differences may be contributing to widening inequalities in obesity accordingly these findings suggest that the current global focus on overall moderatetovigorous intensity activity may mask important behavioural inequalities

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introduction adolescents are the next generation of the nation whose character is very important to be educated and shaped so that they become strong individuals and have a high sense of patriotism a strong character is a fundamental attribute that guides the way of thinking and behaving to live and work together both within the family community nation and state 1 however given with the increasing complexity of social problems such as juvenile delinquency 2 narcotics and addictive substances abuse 3 promiscuity 4 and radicalism 5 special efforts are needed to instill tough character and love homeland in youth in facing the adolescence which is full of challenges and temptations a strong character will greatly assist the youth in making the right decisions and dealing with problems wisely attention to youth character education today is increasingly urgent and crucial this is because adolescents are an age group entering a transition period from children to adults at this time teenagers tend to be more easily influenced by their surroundings especially by peers and social media therefore efforts are needed to instill tough character in adolescents so that they can face various challenges in life and the mosque is one of the right places to conduct education and characterbuilding for this young generation the role of the mosque in the education and character development of youth is very relevant considering that the function of the mosque is not merely a place to perform congregational prayers various muslim affairs education and even justice during the prophets time were carried out in the mosque 6 during his time the prophet muhammad pbuh functioned the mosque as a place of worship a meeting place a place for consultations a place for social activities a place for treating sick people and a place for fostering people and preaching islamiyah 7 in line with the ideal function of a mosque the almuqorrobin islamic center mosque which is located in pringgan cepit pendowoharjo sewon bantul district began its construction on 1 september 2019 ac 1 muharam 1441 ah and has a vision of becoming a center for worship social cultural economic education and health for the congregation therefore all mosque activities in the form of administration prosperity of the mosque and development and development activities 8 are strived for and dedicated to the service and comfort of all congregations although not yet ideal the almuqorrobin islamic center mosque has provided training for the mosques children and youth through the formation of the almuqorrobin islamic center mosque youth group which is now chaired by aqil syahru akram mosque youth play an important part in the mosques prosperity people regeneration mentoring young muslims through routine studies and supporting mosque takmir activities such as dawah and social activities 9 this community partnership program in collaboration with the almuqorrobin islamic center youth mosque aims to empower partners in resolving the critical problems they face namely a lack of alternative partner activities in order to prosper and empower partner members particularly in education and the formation of strong mosque youth characters this article discusses how training mosquesbased of didikan subuh 10 and the tapak suci martial arts 11 can be used as a means to instill strong character and love for the motherland in children and youth at the almuqorrobin islamic center mosque cepit sewon bantul subuh education at the mosque can provide positive religious values such as discipline honesty and love for others while tapak suci martial arts is one of the martial arts schools under the auspices of the indonesian pencak silat association which has been trusted by muhammadiyah movement to form superior of strong cadres tapak suci is a form of pencak silat that avoids shirk behavior and believes that all power comes from allah swt instilling islamic values based on the alquran and assunnah is the goal of tapak suci 12 the characteristics and mission of tapak suci are very relevant to be adopted as a means of education and building a strong character among the mosque youth the combination of the two educational models within the almuqorrobin islamic center mosque is expected to be able to develop the character of mosque children and youth who are strong resilient and also have a high sense of patriotism through the integration of these two activities mosque youth will be educated to become true muslims who respect diversity build selfconfidence and have the ability to protect themselves and society the merging of the two mosquebased educational models for children and youth is a reconstruction of the classical suraubased educational model in minangkabau which has succeeded in producing national figures 13 in various fields such as warriorsheroes proclaimer of indonesian independence successful entrepreneurs educational figures scholars etc it is hoped that this article can provide inspiration for teachers parents and the community to support programs that combine dawn education and pencak silat martial arts at mosques to instill strong character and love for the country in the younger generation thus youth will become individuals who have noble characters have a sense of love for the motherland and be able to bring positive changes to society and the nation methodology the methods used in organizing the subuh education activities and the practice of the tapak suci martial arts are lectures questionandanswer demonstrations and imitating exercises the lecture method is carried out through the delivery of a subject matter by way of an oral narrative to the participants of the program meanwhile the most important student learning activities are listening carefully and noting the important points put forward by the teacher 14 the questionandanswer method is a way of delivering lessons through questions from students to teachers or vice versa from teachers to students this method accustoms students to express what comes to mind without shame or fear so as to foster a sense of love for learning 15 through a very participatory process meanwhile the demonstration method is a way of learning by demonstrating something in front of students by using the demonstration method the teacher has activated all of the students sensory organs 16 this method is very suitable in the teaching of jurisprudence especially in demonstrating the correct procedures for worship as well as in demonstrating certain moves in the tapak suci martial art through this demonstration method students will learn effectively through the 3n process developed by national education figure ki hajar dewantara 17 namely paying attention and imitating and developing result discussion there are three stages involved in the implementation of this subuh education program and the tapak suci martial arts training namely the preparation stage the implementation stage and the evaluation stage the following describes each of these stages a preparation stage several things have been done in preparing for the implementation of the subuh educationprogram and the practice of the tapak suci martial arts at the almuqorrobin islamic center mosque including first holding a meeting to coordinate technical preparations for organizing activities the service team has held several coordination meetings with partners starting from the preparation of the proposal to the preparatory meeting before the implementation of the activity second preparing the subuh education learning material which includes material on aqidah worship memorizing selected surahsverses of holy quran hadiths prayers morals mahfudzat etc third prepare permanent teachers for subuh education fourth determine the permanent teacher of tapak suci the permanent teachers who will train the tapak suci martial arts are the swordsman rowin harry aprinal who is one of the administrators of the takmircongregants of the almuqorrobin islamic center mosque fifth conducting dissemination of the program to the community as well as registering potential participantsstudents of didikan subuh and tapak suci it was targeted that 20 children and youth will register as didikan subuh and tapak suci students as an attraction of this activity the 20 participants who register will be facilitated with tapak suci uniforms the form of dissemination is carried out through flyers which are viral through the social media whatsapp mosque teenager groups jamaah masjid groups and outdoor dissemination media in the form of banners the following is a flyer and banner design as well as a whatsapp group that has been formed to support the socialization and communication process to the communitycongregation as well as participants and parents b implementation the implementation phase of the program includes several series of activities namely first acceptance of registration for didikan subuh and tapak suci participants and uniform measurements second trials for the implementation of subuh education activities and the practice of the tapak suci pencak silat third the implementation of the grand opening fourth the implementation of the weekly didikan subuh and tapak suci exercises the following is an explanation of each series of activities participant registration and uniform measurement registration for didikan subuh and tapak suci participants was open for 14 days starting from january 22 to february 5 2023 unexpectedly the responses of the congregation and prospective students to this program was very encouraging as indicated by the number of registrants outside the mosque youth management reached 35 participants or almost double the estimated amount trial of the implementation of didikan subuh and tapak suci practice trials of the implementation of the didikan subuh and tapak suci exercises were carried out on february 5 2023 didikan subuh activities began right after the fajr prayer in the congregation concluded didikan subuh trial class begins with the implementation of the pretest followed by writing reading imitating explaining and memorizing an arabic proverb which contains wisdom lessons and a wellknown philosophy of life for success namely man jadda wajada with this mahfudzot it is hoped that students will have a paradigm of life that only people who are serious will succeed in life whereas people who are lazy will experience failure 18 pretest the practice of wearing the tapak suci uniform and belt grand opening the official and ceremonial opening of the didikan subuh and martial arts training activities of the tapak suci pencak silat for children and youth of the almuqorrobin islamic center mosque was held on 12 february 2023 drs hm afnan hadikusumo general chairperson of the tapak suci central board as well as senator of the regional representative council of the republic of indonesia is pleased to be present to inaugurate the start of the didikan subuh activities and the opening of the tapak suci college at the almuqorrobin islamic center mosque drs hm afnan hadikusumo officially opened the didikan subuh and tapak suci training activities by reciting bismillahirrahmanirrahim followed by cutting the ribbon to uncover the name plate of the tapak suci college almuqorrobin islamic center mosque and sticking osegu weapon there are some people attending and giving remarks at the grand opening such as the head of lpm umy dr ir h gatot supangkat mp ipm asean eng the member of dprd bantul regency hm ichwan thamrin village head of pendowoharjo and mr h hilmi hakimuddin spdi this activity was also attended by the head of the community service team and members of the service team prof dr muhammad azhar nurul satria abdi sh mh kiki kurniawan administrators and warriors of the tapak suci from the pengda tapak suci special region of yogyakarta and the pengda tapak suci bantul regency in this occasion the inauguration of the tapak suci college board of almuqorrobin islamic center mosque was chaired by aqil syahru akram who is also the chairman of the mosque youth drs hm afnan hadikusumo stuck the osegu weapon marking the opening of the tapak suci college at the almuqorrobin islamic center mosque and inauguration of the board of tapak suci mic almuqorrobin college by the chair of the tapak suci regional pengda bantul regency remarks by the head of lpm umy dr ir h gatot supangkat mp ipm asean eng and remarks by the village head of pendowoharjo h hilmi hakimuddin spdi in the grand opening nasrullah as the headperson in charge of the program said that the aim of the subuh education and tapak suci pencak silat activities is to make the mosque lively and form the character of the young generation who are strong love the mosque and love the country the combination of these two activities was inspired by the surau tradition in minangkabau in the past which has succeeded in producing many strong national figures and muslim entrepreneurs head of community service institution of umy dr ir h gatot supangkat mp ipm asean eng welcomed the program that was launched and thanked the community service team led by nasrullah as well as the program partner almuqorrobin islamic center mosque youth meanwhile m afnan hidikusumo in his remarks explained the importance of the role of didikan subuh and tapak suci in building the character of the younger generation especially among children and adolescents at the almuqorrobin islamic center mosque according to afnan these two activities are very relevant in overcoming the social problems of adolescents who are currently experiencing social alienation as a result of the rapid development of information technology similar comments on the impact of gadgets that have become everyday friends for todays children and adolescents and the urgency of creating alternative interesting activities for them were conveyed by representatives of community leaders muhammad ichwan thamrin and representatives of the local government h hilmy hakimuddin in the occasion all the figures who gave remarks at the grand opening of the subuh education and tapak suci college of the almuqorrobin islamic center mosque hoped that these two activities would become effective and educative tools in forming and fostering a young generation of muslims with noble and strong characters weekly routine activities of didikan subuh and tapak suci didikan subuh and tapak suci training activities at the almuqorrobin islamic center mosque have not yet been completed with the holding of the grand opening ceremonial activities on february 12 2023 the objectives of the two integrated activities to shape the strong character of mosque youth will only be achieved if the activities can take place regularly and continuously consequently these two activities should not stop with the end of the community partnership program the success of character education can only be achieved through a process of internal quality assurance both organizationally and individually in a sustainable manner 19 so far partners have succeeded in maintaining the continuity of didikan subuh and tapak suci since they were first launched until now the rundown of the weekly didikan subuh and tapak suci activities held routinely every sunday starts from 0430 0445 with subuh prayer in the congregation and then it is followed by didikan subuh from 0445 0600 at 0600 0615 the participants take the breakfast provided by the mosque youth after taking the breakfast the mater of tapak suci mr rowin harry aprinal leads the martial arts of tapak suci until 0800 am c evaluation assessment of the success of didikan subuh activities has been carried out through the pretest which was conducted on 5 february 2023 and the posttest on 14 may 2023 the results of the pretest and posttest assessments of didikan subuh participants showed that there had been an increase in religious insight knowledge and nationality of the participants significantly from an average of 326 in the pretest to 64 in the posttest the following is a comparison graph of the results of the pretest and posttest of didikan subuh participants who joint both tests the participants who only took one of the two tests are not shown because they could not make comparisons between before and after the test the evaluation of the program is not enough by showing a record of success there are also several notes of obstacles in the implementation of the program including first the tapak suci college of the almuqorrobin islamic center mosque so far does not have a mattress that can be used as a means of supporting the training second the commitment of the participants in the subuh and tapak suci dikan suci is still fluctuating third the partner does not yet have a permanent didikan subuh teacher and fourth the subuh education module is not yet available the followup plans that need to be carried out for the development of didikan subuh and tapak suci college in this mosque include first partners are encouraged to procure mattresses second partners are advised to periodically send students to take part in religious competitions and tapak suci competitions to increase the enthusiasm and motivation of participants in participating in subuh education and tapak suci training third it is suggested that takmir raise the mosques keepers from among students who can also act as teachers of didikan subuh and fourth mentoring the didikan subuh to develop a more planned and measurable didikan subuh curriculum as a form of feedback on the collaboration in organizing didikan subuh and tapak suci training the chairperson of the youth mosque aqil syahru akram stated that the activity initiated by the community service team from lpm umy had brought a new color to the activities at almuqorrobin islamic center mosque these two activities have encouraged children and adolescents surrounding the mosque to worship and also to be physically active this program certainly brings fresh air to todays young generation who are too dependent on gadgets as their daily playmates partners hope that didikan subuh and tapak suci activities can continue so that later from the tapak suci college of the almuqorrobin islamic center mosque a young generation of muslims who are strong have noble morals have broad insight and are diligent in worship will be born conclusion the mosque as it has been practiced since the time of the prophet did not function as a place to hold congregational prayers only but has multifunction covering social economic cultural and educational aspects needed by the congregation and the community around the mosque the prosperity of a mosque is determined by the ability of its management to maximize its function as the name implies the partners mosque has a vision of becoming an islamic center or a center for religious educational social and cultural activities including as a means of forming and fostering the character of children and youth to become ideal muslim personalities who are tough courageous have good morals are skilled and broadminded the implementation of continuous didikan subuh and tapak suci martial arts training at the almuqorrobin islamic center mosque has based on the evaluation results succeeded in becoming an alternative and mainstay activity of the almuqorrobin islamic center mosque youth in character building of its members who are strong and become an attraction for them in loving and prospering the mosque similar activities deserve to be duplicated by other mosques in the context of the prosperity of the mosque the program team expresses its highest appreciation and thanks for the contributions of all those who have contributed to the success of this community service in particular to 1 head of umys community service institution who has approved and provided a budget for the implementation of this community service program acknowledgement

one of the functions of the mosque that almuqorrobin islamic center mosque wants to play apart from being a comfortable place for mahdah worship is as a place for the formation of the young generation of muslims who are strong in character however so far this function is still not optimal while the interesting activities of youth mosques to prosper the mosque and form the mentality and awareness of defending the country among its members are still very minimal for this reason this community partnership program offers 2 sustainable activities to address the problem of youth mosques as the program partner namely 1 the subuh education didikan subuh activities after the fajr prayer in the congregation every sunday morning 2 the practice of martial art tapak suci selfdefense which is carried out after didikan from 6 to 8 am the methods used in these activities are lectures dialogue demonstrations and exercises led by a professional martial arts trainer the results of the pretest and posttest assessments of the didikan subuh participants showed that there had been a significant increase in the participants religious and national insights and knowledge from an average of 326 in the pretest to 64 in the posttest while the results of routine tapak suci martial arts training since february 5 2023 have produced 2 champions of the tapak suci inter kindergarten and elementary championships throughout the

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introduction israel is a significant regional player in the middle east the future of israel will have major effects on the region in its entirely discussion about the future of the israeli economy scientific advances and military development are obviously extremely important however demography is as important if not more so there is a substantive body of scholarship concerning the demographic changes in the jewish and palestinian populations in israel judea and samaria but that is not the only point of interest in israeli demography in recent years we have seen a growing scholarly interest in quantitative developments concerning one segment of the jewish population namely the haredi community 1 the future of this community and its role in israeli society has been a topic of interest to many scholars and a recurring theme in the scholarship on the issue was the limited and many times absence of general education curriculum the haredi community in israel is the youngest community it grows at a higher rate than that of the arab population in israel the calls to introduce more secular education are motivated both by a desire to acculturate the haredi population and bring it closer to the norms and values of the israeli discourse and by a wish to integrate more people from this community into the job market calls to introduce more secular education in the haredi system have seen constant resistance which has been documented in the scholarship in general this resistance is explained by the perception of the introduction of secular education as an attempt by the secular establishment to introduce foreign and secularnamely antireligiouscontent and values to the haredi community this discourse states that general education is not neutral as far as values are concerned suggestions to include general education are dismissed as an attempt to secularize haredim from within the definition of haredi is not as clearcut as it used to be the growth in this sector created more subsections that differ from one another for the scope of this article i define the term haredi as referring to orthodox jews who view modernity critically and reject zionism as a secular national movement as a part of this rejection of zionism and the legitimacy of secular jewish nationalism members of the haredi community do not by and large serve in the israeli military 2 in the us the discussion on the correct role of general education started from a different frame of reference the existence of meaningful religious education was put into question and only after the holocaust did american orthodoxy significantly expand its educational options this text will describe the diverse spectrum of haredi educational institutions and their approaches to secular education i am using educational institutions located in monsey as a test case since it is a good representation of the kaleidoscope of orthodoxy in the us as far as the different communities are concerned it is also a very decentralized community since there is no dominant group in monsey this fact allows for more initiatives including educational initiatives to be undertaken the educational discourse in monsey with its different versions of orthodox communities can show how different models of secular education have emerged in similar economic political and sociological conditions to fulfill the needs of different communities on the orthodox spectrum the results show that the american jewishorthodox spectrum has created several models for the integration of secular education these models all have something in common they view general education as utilitarian and vocational in nature and reject the ethos of liberal arts education that being said this rhetoric is not uncommon in the us and is becoming more popular with the changing landscape of higher education in the us american orthodox models can serve as a useful template for initiatives in israel where economic questions are part of political discussions concerning haredi education educational trends in the haredi community in israel the haredi community is faces with poverty it has been facing poverty from its inception 3 and while there has been a decline in the rate of poverty it is still very high in 2020 42 of haredi families were categorized as being under the poverty line 4 this decline is an obvious example of the change that this society is going through a transformation of its approach to torah study economy and more importantly its relationship with the secular world and its values scholars of the haredi community agree that the questions of education are critical for the future of the community but also to that of israel in its entirely considering the projections that by 2065 about 40 percent of israeli jews will be haredi 5 projections for the distant future should be considered cautiously however they do not change the fact that the characteristics of haredi education have enormous influence not only on religious culture but also on the economy of the haredi community even if we assume that there will be a decline in the growth of the community in recent years haredi has been the community with the highest birthrate in israel according to the israeli central bureau of statistics since the beginning of the decade the birthrate among haredi women has stabilized at 66 children per woman a slight decline from a little over 7 in the previous decade 6 even though there has been a rise in the birthrate in all segments of the jewish population from secular to religious there is no doubt that we can assume two things first the haredi community will continue to be a young population second this population will play a growing role in israeli society its options concerning participation in the economic structure are crucial for the future of israeli society notwithstanding this fierce opposition recent years have seen changes in haredi education which scholars are only now beginning to describe there have always been haredi institutions that have included general education in one form or another however recent decades have seen a growth in the number and a diversity in the options for example the establishment of the stateharedi school network in the ministry of education this led to the establishment of schools that offer haredi families an option for a rich religious curriculum with substantive secular education while maintaining haredi cultural norms 7 another example would be academic programs targeting the haredi population that are conducted by israeli academic institutions in several disciplines mainly those who tend to be described as vocational such as law business management healthrelated training etc 8 these programs offer haredim culturally sensitive programs that lead to academic degrees and which consider the lack of foundation in secular education that many of these students have 9 recent data show that while these programs are growing by leaps and bounds the overall percentage of haredi students is still low the 13000 haredi students enrolled in the 20192020 academic year comprise only 4 of the entire student population 10 these programs allow the graduates to be integrated in the economic life of israel and find jobs that were in the past closed to haredim this process however is deemed to be slow by many the gradual decline in government support for families in addition to the changing norms in the haredi community surrounding materialism 11 seem to further the interest in vocational paths however at the same time these changes have attracted fierce criticism from community leaders who see this as a threat to the spirituality of the community and as a pathway for the influence of liberal values and norms 12 the scholarship on this topic glosses over the internal opposition that faces these academic programs but it is worthwhile explaining that at the core of this critique there are powerful arguments that have a significant effect in the haredi community a number of years ago in a public forum of the online journal tzarich iyun the topic of haredi students in academia was discussed the editors choose to include a short public speech given by a rabbi at a beisyaakov convention in israel the speech characterized the dangers of academia as a culture war the secularists and the half religious half secularists do not want us to stop performing mitzvot they say please perform mitzvot but be like us live with us have the same interests the same values 13 the existential experience of the haredi student is that of loneliness rabbi nechemya steinberger the director of the haredi students program at hebrew university in jerusalem surveyed the difficulties faced by typical haredi students some were sociological and others wereat least potentiallytheological this sense of loneliness he wrote can only be dealt with by creating a sense of community that will situate the haredi student within the haredi cultural context 14 the existence of haredi programs in israel is a given at this point it is also a given that the quantitative data show a clear obstacle in the growth in the participation of haredi students in both vocational training and the labor market the internal discourse in the haredi world seems to have been overlooked during this discussion on a regulatory level in israel the latest example would be the supreme court case concerning genderbased programs for haredi students the basic question of what haredi students want is quite unclear 15 this internal point of view of the process means that a comparison to the us haredi community is a very effective tool a more complex view in the nonisraeli haredi world has been of interest among scholars for some time the comparison to the us is a natural trajectory when it comes to the labor market 16 this is a question that piqued the interest of amiram gonen over twenty years ago and which brought many other scholars to analyze the ways in which the haredi community in the us forged a complex coexistence with secular studies and the labor market the connection between the haredi communities in israel and the diaspora theoretical framework what is the nature of the connection and relationship between haredi communities inside and outside of israel on the one hand there are similarities in external characteristics such as clothing and shared values but there are also some important differences such as economic structures kimmy caplan noted that the englishspeaking haredi presence brings with it changes to the social fabric of the haredi community in israel finally the presence of american yeshiva students should be seen in the context of the growing numbers of haredim from english speaking countries especially the us who relocated to israel their presence in the heart of haredi populated neighborhoods such as jerusalems meah shearim and geulah has a growing influence on the public sphere as can be seem on geula street 17 while an important part of the haredi discourse in israel is the rejection of western culture the haredi communities in the us are a conduit to ideas and norms from western culture caplan explains this through it being a result of the historical legacy of american orthodoxy that was less insular additionally it can be explained by the fact that these communities are middle class in nature allowing for a consumer culture that limits insulation 18 this last point is very apparent when looking at the most striking example kiryas joel this village in the us was experiencing great poverty in 2010 redefining poverty in the context of the us by combining both community and federal and state assistance even families with limited income could live a life with food security housing transportation and education without having an experience of poverty this redefinition of povertyas both the washington post and the new york times dubbed itis a great example for the very different experiences of haredi life in the us these experiences do not center around poverty and have a consumer culture that resembles the larger american public 19 the haredi american model represents a more complex relationship with western culture american haredim like middle class american protestant fundamentalists seem to understand that one can acculturate without assimilating however upholding torah is paramount and therefore they tread very carefully between the potential threats of american or western culture in order not to lose the bonds that keep followers within the haredi folds by living in the west haredim have adopted a modos vivendi with western culture 20 it is useful to analyze this relationship from the prism of the theory of transnationalism this idea focuses on communities of immigrants that maintain their connections with their country of origin and who choose a path of acculturation rather than assimilation in their new country 21 this is a recent phenomenon in the past immigration meant assimilation within a generation the ease of international communication travel and access to the internet 22 allow for a sense of transnationalism this is a way to acculturate in a host society while maintaining a strong sense of national particularity 23 the relationship between haredi communities in israel and the diaspora has many traits that fall under the title of transnationalism i believe that the fact that the religious leaders of orthodox jewry were almost exclusively centered in israel after the holocaust created this relationship that positioned israeli orthodoxy as center and the diaspora communities as periphery the technological innovations of the second half of the twentieth century made the relationship between this center and periphery relatively easy allowing this model of transnationalism to evolve and be sustained concerning our discussion on the connection between education models in the us and those in israel it is worthwhile to utilize a term coined by thomas faist transnational social spaces he uses this term in opposition to the traditionally discussed social fields social fields are generally defined by physical features boundaries or territories and they maximize the role of governmental and intergovernmental organizations as primary actors in transnational exchange faist argues that social spaces on the other hand transcend the physical world to include communications technology and are characterized by the circulation of ideas symbols and material culture 24 these social spaces more encompassing and inclusive than social fields 25 are especially valuable to the transmigrants who are constantly negotiating the different and possibly dueling identities of their home and host societies the field of education is an example of such a transnational social space physical schools are social fields where the curriculum and educational agenda are imported from haredi educational systems in israel this conduit allows for a dialogue concerning both education and other societal values and norms this conduit is not a oneway street it functions in the same way that communities in the diaspora used it to import from israelit has the capacity to be a twoway street in 1990 amnon levi had already pointed to the possible influence of the us haredi communities in israel 26 kimmy caplans work showed that indeed this is an evolving process that suggests several paths of influence monsey jewish community background the jewish community in rockland county has been growing exponentially in the past decades the soaring prices of housing in brooklyn have brought jewish orthodox families to look for affordable housing options in the monsey area of rockland county ny and the lakewood area in ocean county in nj the families moving to these destinations are young and the high birth rate in these communities creates a vibrant and constantly expanding educational network the goal of this paper is to examine the framework of existing secondary educational institutions in monsey specifically the scope of secular studies and trends in the community concerning higher education based on the assumption that education is a tool that enables social and economic mobility the paper sets out to examine what actions can be taken to increase and diversify educational opportunities in the community the data and analysis in this paper can be used as a foundation for discussion concerning the social advancement of the monsey community and for identifying similar strategies that can be used in israel there are several key questions that need to be answered when it comes to policy is the goal to lift people from poverty and enable them to be independent from social security assistance is the goal to integrate members of the haredi community into the us middle class is the goal to encourage people to acculturate this complex and wide array of educational institutions deserves special attention for several reasons 1 it is a network of institutions that represent almost the entire gamut of educational perspectives and cultures within orthodoxy and could serve as a test case for the future of orthodoxy in america 2 since monsey is not too far from the community centers in brooklyn it has the ability to affect policies and cultural norms in these communities at the same time the fact that monsey and its educational institutions are not firmly in the center of these communities and their leaderships creates the potential to be open to educational experimentation and initiatives the community has been showing consistent growth for many years the 2010 federal census found 311687 residents in the county and estimated that in 2017 there would be 328868 residents 27 in the census there was no category for orthodox affiliation and it is most likely that jewishorthodox families identified as white based on that it seems that 30 of the population are younger than nineteen 28 in the county 7166 families identifying as white reported receiving nutritional assistance in the form of food stamps 29 only 40 of the population in the county had a bachelors degree 30 and in 2010 668 reported that yiddish is their first language and 115 reported that hebrew is their first language 31 the majority of the children in the county are part of the east ramapo school district but most of the children in the district attend private educational institutions in the school district 8900 students are attendees at 14 public schools compared to 20000 students attending 80 nonpublic schools according to the east ramapo board of education 32 the changing demographics and the limited financial support from the school district to the nonpublic schools has been a constant political flashpoint between the orthodox community and the larger population as time went by the majority of the board members were orthodox men and they were accused of being responsible for the deterioration of the public school system menachem berkowitz a member of the school board estimated that these numbers are likely not accurate in light of the constant growth in the number of students in private institutions and the limited information the board has on private institutions primarily he cited the fact that private schools that are not receiving any services from the board of education will not be on record 33 berkowitz noted that after years of tensions between the orthodox and the nonjewish population concerning the school board recent years saw a positive atmosphere and growing collaboration the private schools receive support in the form of busing special education psychological services and financial support that is given per student for security additionally textbooks and other services are provided which are not connected to the religious goals of the schools while the estimation concerning a more positive atmosphere might be contested it is clear that the only population growth in the district is within the orthodox community making the political strife concerning the school district and its finances less volatile politically the jewish community in monsey has a very limited view of the political process members of the community are involved in issues that directly relate to them such as funding for busing and zoning for synagogues and schools however there is hardly any public discussion on issues concerning larger political questions for example in yiddish newspapers voting drives exclusively target the democratic party as it has been determined that the community can gain the most by voting for the democratic party in another example new square a small village populated exclusively by a skver chasidim community votes as a bloc for the democratic party because of a longstanding alliance with the clintons following bill clintons pardon of a community member during his presidency haredi isolationism prevents it from having a meaningful part to play in the american political process 34 the trump election in 2018 created a shift in the political identification of the haredi community but there remains a difference between the presidential elections and the local ones as far as voting patterns are concerned 35 the orthodox community is not homogenous it divides into many factions and subfactions that differ from one another in many ways some big and others small as a result there are different educational models in orthodox communities that need to be discussed separately in light of differing views on secular education and engagement with american society and the job market this report will begin with a general survey of the different communities in the monsey area and will later continue with three separate chapters discussing the major educational categories prevalent in monsey litvish institutions chabad yeshivas and chasidic yeshivas the social framework of monsey there are many differences between the many communities in monsey but there is a wide common denominator that overlaps the entire gamut of the haredi world first and foremost there is a basic ethos of a rejection of modernity this creates a sense of insularity and a very suspicious attitude towards norms coming from the nonjewish world another important pillar is the centrality of torah study the study of the torah is presented as the goal every jew should aspire toleaving everything else as secondary part of this notion is that for the sake of torah study physical comforts should be sacrificed therefore materialism is presented as negative and counterproductive as far as spirituality is concerned 36 the characteristics of the litvishmitnagdish community can be divided to several categories externally most of the men in the community will not have beards unless they hold a religious position of some significance the men will wear modern suits and will speak english for the most part the community emphasizes torah study as the center of religious life and celebrates a model of a man that will dedicate his life to torah study at the expense of economic success this orthodox community in monsey began its growth in the 1950s when a prominent litvish yeshiva beis midrash elyon opened its doors in monsey and attracted families from brooklyn as the years progressed lakewood became the center of the litvish community in the us thanks to the establishment of the worlds biggest yeshiva by rabbi aharon kotler in lakewood nj that being said in light of the housing costs in lakewood there is continued growth in the litvish community in monseythough it is secondary to the rise in the chasidish population 37 in monsey the litvish community is decentralized and there is no dominant rabbinic leadership that spans the many litvish synagogues in the area this community is best described as a spectrum rather than a binary there are members of the community which are integrated into secular society holding professional jobs and supporting educational models that integrate secular and religious studies others are more critical of the integration of secular studies and might promote an ideal model of a kollel student who learns all day and receives community support by those members who cannot or will not commit to a life of study therefore these individuals peruse a professional career and fulfil their religious duties by supporting those who are interested in a fulltime commitment to torah study in other words the litvish community as a spectrum has a side to it which finds much in common with the rightwing modern orthodox community as far as financial expectations are concerned 38 another distinct community in monsey is chabadlubavitch this chasidic group includes several hundreds of families but is growing every year because monsey is still an affordable option for families who cannot afford housing in crown heights this community has an outreach mentality that is evident in the thousands of outreach centers created by this community all over the world this being said not all of the members of the community are comfortable with interactions with society at large those who do not go to establish outreach centers create communities that exist with an inherent tension between insularity and interaction vis à vis secular society the ethos of this community centers around a robust tradition of intellectual religious experience specifically of theology in the past sixty years this ethos developed to include the teachings of the last lubavitch rebbe rabbi menchem mendel schneerson who built his community on the duty to be involved in outreach activities in every possible venue such an agenda brought about the participation of members who are committed to outreach work as well as that of community members that are less insular in comparison with other chasidic groups this results in a willingness to venture outside of the jewish community when it comes to business or the job market 39 the importance of the monsey community for lubavitch is twofold first it is close to the heart of the community in brooklyn which is a main attraction that brings a constant flow of families to move to the area the area is more affordable than any other alternative in the ny metro area second it is far enough from brooklyn to be comfortable to test community boundaries and norms since it is not in the immediate vicinity of leaders in the community but it is still close enough to be visible to the crown heights community and cause residents of crown heights to rethink and reevaluate the way they do things the chasidic community in monsey is very large and consists of several subgroups the communal lives of these communities are conducted exclusively in yiddish in the cases of square vishnitz and satmar it is easy to find men and women who are thirdgeneration american citizens who speak broken english this communities which are mostly of hungarianromanian decent are more extreme in their rejection of outside influences there are other smaller hasidic communities in the monsey area which are less restrictive in light of their smaller size and the fact that their community centers are located in israel or brooklyn this is the case with ger belz tzans bobov karlin etc 40 these are polish hasidic groups and are slightly less insular and less critical of the state of israel chasidic educational institutions in the chasidic community there is a clear hierarchical structure at the top of the pyramid is the tzadik usually referred to as a rebbe or admor in the established and large communities the rebbe or admor has the last say on community policy and life and sometimes on the personal choices of individuals in monsey the largest communitiesnamely skver and vishnitzhave their rebbe living in their immediate vicinity making his control more felt and present the governing ethos of the different chasidic communities is insularity these communities pride themselves on building walls between themselves and the outside world this is exemplified by their unique clothing language and their public rejection of traditional mass media and social media however in the past decade there have been changes in the levels of insularity the internet and the ability to access it with anonymitywhile hiding this access even from members of the familyhas been creating shock waves in chasidic communities this new reality has had significant impacts on the community in many different wayseconomically educationally and normatively there are many members of the community who are opening businesses which function in an online environment ecommerce allows members of the community who have limited secular education to open a business and go beyond the boundaries of the community this leads to a greater level of involvement with the outside world and its norms and values leading some to explore ideas and possibilities outside monsey this has also brought about negative outcomes namely an increase in drug use leading to a growing rate of deaths due to overdosing 41 within chasidic communities there are attempts to combat the growing influences of modernity mainly by attacking the main vehicle the internet there are continuous and extensive campaigns warning against the use of the internet and smartphones newspapers magazines and mass gatherings are continuously voicing the dangers of internet the use of the internet can lead to sanctions such as rejecting children from admission to schools the fear of these changes is based in reality there is a growing constituency of families dubbed modern chasidim this term refers to chasidim members who are not comfortable with the yoke of insularity and choose to change their lifestyle from the community norm some will introduce english books to their homes use the internet change their attire to a degree and change the schools their children attend to more liberal and less insular institutions 42 these communities characteristics are extremely important as far as the discourse and action concerning social changes are concerned the different subgroups of the monsey orthodox community while having much in common have different levels of tolerance to modernity and have different needs as far as their educational institutions and economic structures are concerned any kind of project in monsey attempting to bring about social mobility and broaden the economic venues that are open to members of the community will need to be tailored to these cultural and normative boundaries without acknowledging these sensitivities any such project is doomed to fail litvish secondary education the secondary education institutions for litvish boys can be roughly divided to two categories yeshivas with secular studies that fulfil the minimum requirements of the state of ny as far as secular education is concerned including the regents exams yeshivas which are exclusively centered on torah study and include no secular education at all most of these institutions do not have boarding options so the students are local for the most part this makes these institutions smaller and very connected to the culture of the local community the daily schedule of the students is demanding the day begins at 730 am with davening after breakfast gemara studies begin at 930 which will include independent study and a shiur lunch is at 100 this is followed by another seder at 2 pm in yeshivas with a high school component secular studies will take place between 330 and 6 in almost all the yeshivas students will go home at 6 only to return at 730 or 8 for night sederanother period of an hour or ninety minutes for talmud study traditionally in the united states the litvish yeshiva for high school age usually referred to as yeshiva ketana includes secular education institutions such as torah vdaas chaim berlin telz etc were created in america and integrated secular studies with the understanding that their graduates require a pathway to livelihood however this model is facing competition from what has become known as the lakewood model in lakewood the biggest yeshiva in the world rabbi aaron kutler created an ethos which was known in yiddish as nar teyreh this ethos which until this day controls the haredi discourse in israel proclaims that children and young men should study only the torah disregarding issues of potential employment in the future 43 in america these two competing models live side by side in israel there is severe criticism and vitriol against the inclusion of secular studies in haredi institutions however the american litvish community is able to take a different approach while still maintaining its veneration of the leadership of the haredi world in israel this dissonance is practical not ideologicalthere is no core ideological explanation for this difference it is simply a fact of life that in america things are carried out differently that being said there is considerable room for improvement in light of the fact that some institutions reject secular studies even those that do include secular studies send a conflicted message concerning secular studies namely secular studies are secondary and at best a tool to generate income there is a belief that even true men of faith will not require this knowledge to earn a living and god will provide for them if they truly commit to torah study 44 in an interview i conducted with a longtime educator in a large litvish yeshiva that includes secular studies he states that beisshraga is a great example for a litvish mosad the goal is to take a soft yeshivish home and make them strong litvish they offer regents curriculum but would prefer the students dont go to college but they are not very worried if some do 45 the preferable safe option is for graduates who do not intend to continue to learn and to teach torah to turn to commerce or another vocational path clearly there is a connection between success in the job market and college degrees the college option is problematic in the litvish world since college is identified as a center for promiscuity on the one hand and atheism on the other 46 obviously such an attitude creates a significant barrier between graduates of these yeshivas and a typical american college the college campus is considered foreign in their eyes this approach has impacted the attitudes among the students when asked what the boys think of secular education one student answered as follows boys are interested in a diploma some are naturally curious but there are no aps or cleps all the teachers but one is jewish and religious they do not see people from the outside 47 there are also objective barriers between the community and colleges namely the fact that male students finish their studies in the yeshiva system between the ages of 22 and 25 the second barrier is the price tag of most american colleges which is prohibitive for many families in this community unlike the yeshiva ktana high schools for boys the secondary education institutions for girls follow a different path the litvish high schools for girls usually referred to as bais yaakov tend to be more inclusive as far as the communities that send their daughters to them the bais yaakov institutions have a range of attendees from girls form more modern litvish families in some bais yaakovs to chasidish girls in the more traditional institutions in an interview i conducted with rabbi t an associate principal at a bais yaakov in monsey he noted that the educational visions for girls can be divided into two categories the first is a pedagogical agenda that wants the graduate to be a mother and homemaker this message can be found in institutions such as bais rochel where secular studies hardly exist and an entrepreneurial graduate will most likely open a gift shop or another other small business to express her creative abilities but rabbi t continued to say that some institutions understand that in todays economy a graduate needs to have career options they understand that the graduate should have the tools to acquire jobs that will include some kind of training outside the jewish world 48 in the past fifteen years litvish institutions have created certain pathways to higher education these pathways have recently also begun targeting male students of litvish yeshivas which brings us to the attitude of these institutions to higher education in lakewood there is a tradition of criticism of higher education and graduates of lakewood as i mentioned before criticize any attempt to acquire academic credentials however ever since the 1950s other litvish yeshivas were tolerant of their graduates attaining some kind of academic training in nonjewish institutions currently there are several avenues open for male or female litvish graduates who wish to attain academic credentials to further their career in the job market these graduates will return to the us after spending time in israel for religious studies the average male student will be between 22 and 25 years old sometimes older the female students will be 2021 upon their return they might integrate studying in a local academic institution in the afternoon while spending their mornings in a religious environment such as yeshivas or postseminary programs there are still yeshivas in baltimore and brooklyn where you can find students studying the torah until 3 pm when they then begin their academic studies at local universities and colleges 49 another avenue is dominated by certain private and public colleges and universities who identified the potential of the haredi market these universities and colleges include institutions such as concordia college bellevue university thomas edison state college empire state college and fairly dickenson university they have developed avenues for a ba for haredi students these institutions offer haredi students a shortened period of study by accepting credits from yeshivas and seminaries in israel with apclep credit they are willing to accept transfer credits sometimes up to 90 credits leaving a student with only one year of study to complete in order to be granted a ba these programs offer a combination of online courses and traditional courses held in brooklyn monsey and teaneck which are open only to haredi students and are gendersegregated 50 these pathways will grant students a ba in business management and in some cases education other programs offer a degree in accounting there was an attempt by touro college to create a more rigorous ba program for the haredi world under the title machon lparnasa but in the years since its inception it has not gained popularity several interviewees explained that its small size results from the fact that it is considered a secondrate institution that is run by jews and targets the jewish community additionally and perhaps more importantly it requires students to go through the entire process of academic studies to achieve a ba which many students feel is unrealistic due to their age 51 in an interview with a director of a small program granting bachelors degrees the cultural context of the programs was emphasized the programs chosen by most of the haredi students are those that accommodate their cultural sensitivities and first and foremost take place in a yeshivish setting these programs either take place online where gender boundaries are not needed or if they do take place in a traditional classroom they are singlegenderbased 52 this seems to be an essential part of the integration of haredim in higher education the most significant challenge as it relates to the litvish community seems to be divided into two tiers the first is the fact that there is a certain constituency within this community that sees secular studies as spiritually dangerous and which is not creating paths for its young people to enter the modern job market this reality which originates from the lakewood community became such a strong ethos of the lakewood culture that it overpowers even the current leadership of the lakewood yeshiva in interviews i conducted with community activists in lakewood who enjoy a good working relationship with key figures in the lakewood yeshiva they indicated that the leadership understands that the current economic structure is not viable however they seem to lack the ability to publicly state the need for a change the second tier has to do with the current higher education options that are available to those members of the community who do not follow the lakewood ethos as i previously indicated the colleges and universities that work with the litvish community created specific tracks that tend to be focused on business education and accounting the main difficulty is that these degrees do not have the same social capital they might have had in previous years the changing nature of the job market requires the community to open and access new venues of higher education specifically those that can be easily translated to the job market for example computer science technology and engineering nursing and assisting physicians chabadlubavitch yeshivas and high school the chabadlubavitch community is different from other communities on the spectrum of the haredi world it is more integrated in the nonreligious and even nonjewish world at large and is not invested in creating an enclave society its theology provides underpinnings for engaging with the world in order to foster the worlds moral and spiritual growth and to actualize the spiritual potential of worldly objects and projects there is a selfconfidence born of a long history of strong organizational and intellectual abilities the constant influx of baalei tshuvah also brings with it more points of view and approaches to education and different needs as far as curriculum is concerned 53 the yeshiva for high school boys in chabad communities is referred to as a mesivta you can find them all over the world and they are usually small institutions with populations ranging from 40 to 150 students the daily schedule in such an institution is very similar to the litvish yeshiva ktana with one major exception a third of the day is dedicated not to talmud study but the study of chasidic texts written by the leaders of the chabad movement the vast majority of chabad yeshivas did not include a secular curriculum there are exceptions in the yeshiva in toronto the ocean parkway yeshiva in flatbush and yeshivas in pittsburg australia and a few more locations what is the catalyst to the inclusion of secular studies in chabad it seems that this phenomenon can be traced back to several factors first the fact that chabad communities in some cases create outreach institutions chabad schools target populations which are interested in jewish education but which demand secular studies that are on par with the educational norms in their state this fact brings some communities to open such schools and send children from chabad families to these schools alongside children from nonchabad families such developments in smaller chabad communities have a cumulative effect on the larger community and bring about calls for changes in education a second cause is the changing economic vision of the central hub of chabad in the crown heights community in recent decades many young couples saw their future as shluchim emissaries of the movement establishing outreach centers in various places around the globe in the past decade it has become apparent that there are few new options for such new outposts young families in the community are turning to other career avenues in business commerce etc the growing number of young men and women in the community who are searching for career paths with varying levels of success brings parents to discuss the option of adding secular education to secondary education institutions most girls institutions in chabad include secular studies in ny for example the chabad high schools for girls are based on the curriculum created by the board of regents of the state of ny the official goal of these schools is that their graduates obtain a ny regents diplomaa diploma that opens paths to further higher education the differentiation between male and female education shows that the opposition to secular education in the metivtas has more to do with sociology than ideology in an interview with a businessman from monsey who supports one of the yeshivas in monsey he said the following about yeshivas that include secular studies in the haredi chabad world nonreligious activities integrated in the curriculum are seen as catering to kids at risk kids on the periphery of religious observance they have challenges with their observance 54 when asked about the fact that there are chabad institutions that do offer secular education and are catering to the core of the community he answered to a degree they are considered outside the box but the monsey yeshiva is not main stream but we are trying to be that we are trying to inject certain experiences to jewish education i believe in what the gemara says eview 12 of 20 of the state of ny the official goal of these schools is that their graduates obtain a ny regents diplomaa diploma that opens paths to further higher education the differentiation between male and female education shows that the opposition to secular education in the metivtas has more to do with sociology than ideology in an interview with a businessman from monsey who supports one of the yeshivas in monsey he said the following about yeshivas that include secular studies in the haredi chabad world nonreligious activities integrated in the curriculum are seen as catering to kids at risk… kids on the periphery of religious observance they have challenges with their observance error refer ence source not found when asked about the fact that there are chabad institutions that do offer secular education and are catering to the core of the community he answered to a degree they are considered outside the box but the monsey yeshiva is not main stream but we are trying to be that we are trying to inject certain experiences to jewish education i believe in what the gemara says ‫בגוים‬ ‫תורה‬ ‫אין‬ ‫בגוים‬ ‫חוכמה‬ ‫יש‬ error reference source not found in monsey there were two secondary education institutions one for boys and one for girls the boys yeshiva has gone through many stages and changes in recent years it operates with anywhere between 50 and 70 students in rented facilities this yeshiva offers no secular studies and it could be construed as a typical chabad yeshiva the students come from monsey for the most part while many come from out of town including brooklyn the boys are expected at the conclusion of their three years in the yeshiva to 55 in monsey there were two secondary education institutions one for boys and one for girls the boys yeshiva has gone through many stages and changes in recent years it operates with anywhere between 50 and 70 students in rented facilities this yeshiva offers no secular studies and it could be construed as a typical chabad yeshiva the students come from monsey for the most part while many come from out of town including brooklyn the boys are expected at the conclusion of their three years in the yeshiva to continue to a yeshiva gedola the next phase in their religious education there was a second institution that was created in 2015 and which closed after the covid19 outbreak under the title lev temimim 56 this yeshiva was geared toward what the founders perceived as the vast majority of teenage boys in chabad communities in other words not excellent students who can study torah all day long and excel in it but average boys with average talents the yeshiva was founded with the goal of giving these boys an opportunity for religious growth and selfvalue even without the ability to excel in religious studies the yeshiva integrated secular studies for various reasons in interviews with several stakeholders in this yeshiva it seems that the integration of secular studies defined the yeshiva as a yeshiva for weak boys it is interesting to compare this perception of lev temimim to the local high school for girls the latter called bais chaya mushka was founded and is led by a rabbi who holds a doctorate in physics and operates a full and successful secular studies program that qualifies the girls to take the new york regent exams girls take ap exams in some cases and the secular studies program is a natural and valued part of the curriculum this striking difference proves that the opposition to secular studies within chabad yeshivas has much to do with sociological perceptions and when those change many members of the community would appreciate this option what are the core ideological and sociological obstacles to promoting such a change in chabad there are many chasidim that will claim that the lubavitcher rebbe objected to secular studies while the lubavitcher rebbe did object to secular studies on some occasions when the rebbe said no college it was 1960s it was said in a very specific context namely colleges in the 1960s and their campus culture 57 it is intellectually dishonest not to contextualize this statement in this day and age in reality the lubavitcher rebbe had a much more nuanced complex point of view concerning secular studies well beyond the fact that he himself was educated in academic institutions in berlin and paris he addressed the issue in 1978 in one of his theological discourses here he made it clear that there is religious value in approaching secular studies and revealing godliness within them 58 the dissonance between the economic needs of the community and the perception that there is a spiritual problem with secular studies can be solved in the context of chabad by rebranding secular studies in an interview with a rabbi of a chabad synagogue in the monsey area he notes that the young adults in the communityusually referred to as yunge leit in yiddishhave pursued and are pursuing training in nonjewish institutions postmarriage he gave several popular examples accounting physician assistance studies nursing and coding the popularity of these tracts suggests that in his mind integration of studies branded as professional training within the educational system will be perceived very differently than merely the addition of secular studies to the curriculum finally it is worthwhile remembering that a significant catalyst for changes in education has to do with tuition the price tag associated with religious education is high and a scenario that will allow a yeshiva that offers secular education to cut tuition will enable it to be much more selective and to significantly increase its pool of applicants well beyond the boundaries of monsey the vast majority of young men in lubavitch finish their yeshiva education at 2324 young women will be finished by the age of 1920 many of these young adults will marry soon afterwards with children often coming quickly the ability to begin academic or vocational training is obviously inhibited by the realities of starting a family similarly to litvish couples the need of young adults in chabad is for academic or vocational training that will quickly lead to gainful employment surprisingly most observers point to the fact that young chabad men and women do not turn to the specialized short pathways to a ba when compared to their peers in the litvish world it is hard to explain why this is the case perhaps this has something to do with the culture in chabad communities which is very practical and to the point this leads young men and women to start their own businesses or to prefer more vocational training in 2017 it seems that forces within the crown heights community were able to convince medgar evers college in brooklyn to accept yeshiva credits they pointed to the fact that there are forces in the community that believe relationships with colleges should also be developed similar to those that exist in the litvish world 59 there are many forces within the community that cultivate this culture of entrepreneurship such as crown heights young entrepreneurs an organization geared toward helping yunge leit open their own businesses it seems that programs that will be branded as helping to foster this culture will be accepted as legitimate in the community this would be an opportunity to introduce academic studies in the long run it could also legitimize interest in other fields of knowledge and study beyond the more popular fields of science technology accounting and others as mentioned above a homogenous cultural learning environment will be beneficial in this case also like that in the litvish community chasidish secondary education as i mentioned in the opening of this paper the chasidish community is governed by an ethos of insularity this is exemplified by the clothing language official criticism of mass media and social media and other factors but this ethos is the strongest in the education system inculcated in the students from a young age is the idea that the outside world is a combination of danger and spiritual inferiority part of this ethos is the rejection of secular studies today in monsey there is hardly any kind of secular education in chasidish institutions this has not always been the case in the past even the most stringent and insular communities included secular studies in their elementary education today boys institutions have the bare minimum of secular subjectsif any at all obviously no secular education exists in secondary education for boys the hard core ones have nothing past 12 years old and there is only 45 min a day the rest belz ger vien have nothing past 14 it used to be different in bobov vien perhaps ger had regents exams even satmer had 3 h until the age of 13 i dont think they will change their minds if they will be forced from the outside 60 the above quote is very revealing it seems that the gradual digression from secular studies in the chasidish world had to do with a sense of religiosity one institution started to diminish the amount of secular studies and others followed suit fearing that they would be perceived as less religious even though the community often seems to be a homogeneous group in reality under the surface there are a range of opinions regarding secular education karlina chasidic group with a mediumsized following in monseyis led by a rebbe who is americanborn and raised and is now living in israel he is known to have an openminded and sophisticated world view the community in monsey seems to have many forces within in that would be interested in developing more educational and economic possibilities for the younger generation on the other hand in the core of the viznitz and satmar communities in monsey you will find young men who are thirdgeneration american citizens but speak broken english to whom english is a second language in an interview with an educator from the chasidic community he suggested that there could beperhaps since there are a few scarce examples of secular education in chasidic institutionsroom to establish a chasidic yeshiva that includes secular education the reasoning behind such a suggestion is the objections behind secular education have more to do with sociology than anything else in other words the establishment of an institution that will maintain all chasidic characteristics and which will also include secular studies will be perceived as legitimate by many in the chasidish community while they will not be relevant to very insular communities such as satmar and skverwhere students have almost no exposure to secular studiesand will need considerable remedial work this might be an option for others that come from less insular communities and families in an interview with another community activist he suggested that while this might be a very ambitious project existing institutions might be willing to integrate programs that will be seen as orientated toward vocational training basic programming accounting etc like the other communities surveyed before there is a difference between secondary education for males and for females there are more educational possibilities for chasidish girls includingin some casesregent exams this is the case with bais rochel a highly traditional school that caters mainly to girls from chasidish families you can also find chasidish women using online programs to obtain degrees but it is difficult to ascertain the scope of the phenomenon for young men in the community who usually start families at a very young age there are several trajectories when it comes to providing for their families many start businesses which are connected to commerce and ecommerce there is also a willingness to obtain bluecollar jobs during an interview with a local businessman and community leader rabbi yaakov horowitz he suggested that there is room for the establishment of a trade school he believes there will be significant demand in the chasidish community for this kind of training includingbut not limited toair conditioning technicians refrigerator technicians mechanics carpenters etc he mentioned that in the past he attempted to cooperate with a statesponsored institution training men and women to enter this market however there are some cultural challenges that make it difficult to integrate chasidim from monsey directly into classrooms in such institutions some of these difficulties are technicalmainly the fact that they have a significant part of their classes on the weekends and will not accommodate jewish holidays however there are also more fundamental challenges mainly those which arise when it comes to the integration of chasidic men and women who come from such an insular environment with students from completely different cultural backgrounds its goal is to allow young men from the chasidic community there to integrate into the job market and it has operated successfully for the past several years in an interview with community activists in lakewood they mentioned that many chasidim in lakewood work in such positions women in this community will also be interested in vocational training especially in the fields of accounting and coding the unique cultural characteristics of the chasidic community require a nuanced and culturally sensitive approach in order to strengthen the ability of young men and women from this community to take a larger part in the modern job market while sensitivity is required in relation to the communities discussed before the chasidic community has more cultural barriers such as language fashion and suspicion of outsiders that being said there are many forces in the chasidic community that understand the urgent need to implement changes in the education and training system that is available to community members this is an excellent opportunity to advance and to make such important changes in the case of the chasidish community it is hard to see an easy path to civic engagement the level of insularity and the high rate of poverty in the community accompanied by a high level of dependency on social security creates significant barriers towards civic engagement i do believe however that the creation of vocational training programs and attempts to improve secular studies in secondary education will result in the long run not only in a new economic structure for the community but also in a new political structure summary and recommendations the data collected for this paper suggest that there are several directions that can be pursued in the attempt to increase the educational opportunities that are available in the haredi communities in the us and in israel these need to be sensitive to community norms which differ considerably both within the monsey area and in israel the benefit of using the model developed in monsey is the fact that in monsey this process is in a more advanced stage albeit far from finished the changes in israel began a little over a decade ago and are still in their nascent stages meanwhile in the us the integration occurring in the litvish communities andto a lesser extentin chabadlubavitch communities began long before that the first question is the following how are the models described here able to circumvent barriers that are so significant in the context of the haredi community the difficulties of implementing changes in the field of education in the haredi community have been discussed by many scholars 61 the literature identifies obstacles that can be divided into four categories 1 an ideological barrierthe narrative that innovations are prohibited by the torah is so common in haredi discourse is a significant obstacle the narrative used in monsey is not burdened with this barrier since the discourse is centered around vocational training or parnasa rather than a liberal education narrative that is based on a specific ideological vantage point 2 organizational conservativismin israel haredi education is built around centralized systems such hachinuch haatzmai or communitybased systems this reality creates a level of resistance to change that is no different to that in any other large institution this comprises a significant difference between monsey and us haredi cultures in general where the private educational institutions are decentralized to an extreme and there is no concept of chains of schools with consolidated management this allows for new schools to be established as grassroots action for this model to be transplanted in israel it will also need to be situated outside the existing systems 3 structural difficultiesa point that is reiterated by many scholars is that there is difficulty in overseeing haredi education and assuring the implementation of changes in the context of this model this problem is circumvented since the market andto a lesser degreethe regulators deal with the proficiency of the graduates this point requires further clarification first when it comes to vocational programs such as it the skill level of the graduate determines the marketability the same is true for accounting where a graduate of a program targeting haredi students will be judged according to their skill level when it comes to programs like nursing the licensing authorities will regulate the studies in other words the more vocationally oriented the program the less there is a need to worry about supervision this approach can be relevant to secondary education where outside testing makes the final judgment of the quality and efficacy of the program 4 politicaleconomic power structuresin israel there is a symbiosis between the educational institutions many of whom are part of a centralized chain and the political and religious leadership of the community this is not the case in monsey where the separation of church and state minimizes the scope of the funding that religious schools can obtain from state agencies therefore the power of the political leadership is limited this is an issue that seem to be the most significant barrier to circumvent in transplanting the monsey model in israel the solutioni believeis mainly to be found in building trust with existing systems through agents of change a discourse that focuses on parnasa rather than on an ideological discourse that will fill the void of vocational training and facilitate haredi participation in the job market can be accepted as a genuine attempt to improve the lives of community members secondary education as noted in the previous pages there are different models of secondary education in monsey some institutions integrate secular studies and it seems that many litvish and chabad institutions that do not integrate seem to be willing to consider such integration in exchange for financial support such a grant needs to be conditioned on objective criterion that will ensure that the money is spent in the desired manner since monsey is in the state of new york such grants can be conditioned on a certain percentage of the student body passing the regent exams a similar model can also be used in israel where high school matriculation exams exist and are wellestablished supporting a wide variety of learners in different levels of academic skills and rigor such a condition connected to a measurable criterion would require that an institution commit significant resources to build up a viable secular studies program concerning the chasidish world there could be room for the establishment of a chasidish yeshiva that would integrate secular studies such a project would require a significant grant but there are local educators who are interested and would be willing to take part in such a project such a project might have effects well beyond the boundaries of monsey in israel such a program under the title of hamidrasha hachasidit located in beitar has been operating for several years 62 it could very well be that a similar project in the united states will have positive effects finally even if such an ambitious project might be too challenging there is room to offer grants for chasidic yeshivas that will integrate vocational training as part of their secular education while such programs will need to be more modest in their scope it will have the potential to cause a shift in public opinion and motivate young men and women to explore new career paths higher education as noted there are certain academic avenues created by jewish and nonjewish colleges and universities in recent years there is no need to explain that a ba opens doors in the modern job market that said there is great room for improvement concerning the existing options first many members of litvish and chabad communities do not utilize these existing options second the existing programs tend to be oriented toward fields which are not as relevant in the fastchanging job market there is significant potential for projects that will open up new avenues of academic studies in the haredi community parallel projects in israel are growing constantly a centralized effort to work with and encourage local institutions to create such special programs is essential a focus should be put on the creation of academic programs that are relevant to the contemporary and future job markets as i mentioned before it is obvious that many members of the community are interested in programs to qualify them as physician assistants and computer programmers and in other stem programs it stands to reason that this will also motivate those interested in other academic programs to pursue such interests in the israeli context there has been considerable discussion on the singlegender structure of the haredi programs this has been challenged in court and the basic question of the need for such segregation among haredi students has been challenged by opponents of the haredi programs in israel the examples from monsey unequivocally show that such separation is a given and it is difficult to imagine any other model in this cultural context the heavy use of online courses in american higher education might also help ease some of the tensions as far as hiring professors is concerned since it seems there is no objection to female professors in online courses for men if the monsey case can teach us anything about higher education it seems that singlegender classrooms are a given for the successful integration of charedi students in higher education at the undergraduate level vocational training specifically in the chasidish world there is legitimacy and motivation to pursue bluecollar professions it seems to be the epitome of the american dreamimproving ones economic reality through hard work there seems to be significant interest in the community in the formation of such a program it is hard to overstate the significance of the creation of many small businesses in a community such as monsey it has the potential to create not only economic change but social transformation and a shift away from heavy reliance on social security and social benefits education can bring about social mobility and change political and ideological positions many orthodox leaders recognize that changes are needed in the orthodox education system in light of the everchanging economy such changes can and should bring about new ideas on the contribution of this community to larger society be it in the us or israel the monsey community can be an epicenter of change for the haredi community in the united states and the models utilized in the monsey context should inform the israeli process concentration on education reform and the introduction of higherquality secular studies programs in secondary education as well as more pathways to higher education will bring about civil discourse in the community and a higher rate of participation in civic life point of difference the theoretical model of transnationalism allows for crosspollination between the center and the periphery in the case of monsey i did not find evidence for the israeli haredi discourse concerning secular studies but that does not mean that this is true for all american haredi communities in lakewood where the litvish dominance is much clearer i found a more substantial rhetoric against secular studies in litvish circles this goes beyond the scope of this article and requires a separate research project it is also important to note that there is one factor that has a dramatic effect on the comparison between the communities military service this issue hasfor decadesbeen a central point of contention between the haredi community and the israeli establishment opening avenues to either academic or vocational training will be connected to the question of conscription the point of view that military service is an agent of change is intended to secularize and acculturate haredi youth into the zionist narrative this will remain at the core of haredi discourse at the same time the degree to which the nonharedi jewish majority be willing to allow pathways to academic or vocational training without some kind of military service remains unclear 20 21 22 concerning the role of the internet in transnationalism see 23 24 25 26 37 38 39 for a discussion on the role of lubavitch in the larger society see 40 41 42 for a brief discussion on this issue see 43 44 for a comparative view see

the haredi community in israel is the youngest community it grows at a higher rate than that of the arab population in israel the calls to introduce more secular education are motivated by both a desire to acculturate the haredi population and bring it closer to the norms and values of the israeli discourse and from a wish to integrate more people from this community into the job market calls to introduce more secular education in the haredi system have seen constant resistance that has been documented in scholarship in the us the discussion on the correct role of general education started with a different frame of reference the existence of meaningful religious education was put into question and only after the holocaust did american orthodoxy significantly expand its educational options this text will describe the diverse spectrum of haredi educational institutions and their approaches to secular education i am using monsey as a test case since it is a good representation of the kaleidoscope of orthodoxy in the us as far as the different communities are concerned it is also a very decentralized community since there is no dominant group in monsey this fact allows for more initiatives including educational initiatives to be undertaken

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introduction during the last decade the phenomenon of overprotective parenting has been the object of considerable scientific scrutiny studies conducted among adolescents and young adults indicate that overprotective parenting may have detrimental consequences as it may put youth at risk for developing a host of psychosocial difficulties including social anxiety more depressive symptoms and more internalizing and externalizing problems in addition research on the antecedents of overprotective parenting has identified a number of parent characteristics and child characteristics that may serve as determinants of overprotective parenting thus past work has mostly considered overprotective parenting as a phenomenon that occurs within the parentchild dyad this is potentially problematic as such a restricted focus on either child or parent factors may reinforce an implicit rhetoric where either the child or the parent is to blame for the childs psychosocial and developmental difficulties this can be overcome by focusing on potential contextual factors which are generally overlooked in the literature on parental overprotection drawing upon family systems theory we aimed to test whether characteristics of the coparental relationship which involves the way parental figures relate to each other in their role as parents are associated with overprotective parenting during adolescence which in turn was expected to relate to more adolescent anxiety such a focus on the coparenting relationship is not only important for gaining insight into its potential benefits for childrens and adolescents development but also may help to overcome the view that childrearing is the sole responsibility of the mother overprotective parenting during adolescence parental overprotection refers to parents provision of protection that is excessive considering the childs developmental level particularly during adolescence and young adulthood developmental periods characterized by childrens increasing strive for independence and selfreliance there may be a higher risk for parents to protect their offspring in ways that do not meet their developmental needs during adolescence parental overprotection may take many forms including parents tendency to solve adolescents problems without help being requested an excessive preoccupation with adolescents health and safety and a tendency to warn the adolescent about every potential danger in their environment although often wellintentioned overprotection may backfire as it is hypothesized to interfere with a childs development of resilience and coping skills potentially contributing to anxiety and other mental health problems such as depression disordered eating and behavior problems in that respect a considerable body of research confirms that parental overprotection is an important risk factor for psychosocial difficulties including internalizing and externalizing problems academic difficulties and anxiety symptoms in particular for instance in a longitudinal study spokas and heimberg found that recollections of overprotective parenting during childhood relates to increases in social anxiety among students when they entered their first year at university similarly lemoyne and buchanan found that overprotective parenting relates to lowered psychological wellbeing to a higher likelihood of having a prescription of medication for anxiety and depression and to a higher likelihood of nonprescribed consumption of pain medication further past research has also yielded insights into the potential determinants of overprotective parenting specifically previous research identified a number of factors related to the child mostly involving child vulnerability such as mental health problems chronic pain or perceived vulnerability due to paediatric conditions similarly specific temperamental factors can also elicit overprotective parenting strategies for instance in a longitudinal study among parents of 2 to 4yearolds rubin nelson hastings and asendorpf found that parents who rated their child as shy and inhibited were more likely to constrain their childs independence in order to avoid psychological or physical risk two years later furthermore previous research identified a number of parent factors that are associated with a greater use of overprotective parenting strategies such as parental anxiety and neuroticism for instance in a study among mothers of young adults brenning et al found that a maternal anxious attachment style was related to more maternal separation anxiety which in turn was associated with more overprotective parenting and a tendency to experience the childs homeleaving as a negative event further in another study it was found that children of a parent with a clinical diagnosis of anxiety disorder more often perceived that parent as overprotective as compared to children from a control sample however while factors specific to the parent and the child provide a running head coparenting and overprotection 6 certain understanding of the determinants of overprotective parenting it is necessary to consider contextual sources of stress and support in which the parentchild relationship is embedded in order to gain a more comprehensive view a focus on family contextual determinants may help to put the phenomenon of overprotective parenting into perspective through the consideration of the larger family context in which such behaviors occur drawing upon family systems perspectives we argue for the importance of considering the coparental relationship as a contextual determinant for the understanding as to why some parents engage in overprotective parenting the coparental context of adolescent development according to family systems perspectives the family can be conceived of as a dynamic system composed of multiple subsystems such as the parentchild subsystem and the coparental subsystem coparenting refers to the coordination between any two adults that share the responsibility for the upbringing of a child previous research shows that coparenting dynamics help to explain why interparental conflict may affect the parentchild relationship and childrens adjustment more generally family system theorists stress the importance of considering coparenting dynamics for understanding how the family contributes to child development herein we expected that coparental triangulation in particular would be linked to more overprotective parenting which in turn would relate to more adolescent anxiety in the literature the term triangulation is used in somewhat different ways but it essentially refers to the process of avoiding or diverting parental conflicts through the involvement of the child in these conflicts this may take several forms such as the formation of crossgenerational coalitions or the detouring of the conflict by focusing on problems exhibited by the child typically triangulating the child is forwarded as a strategy to avoid facing the potential tension or underlying conflict that exists within the parental relationship by diverting attention onto the childs difficulties or problems the parental subsystem is temporarily relieved of the underlying tension and stress existing within the subsystem thus by becoming overly involved with the child parents submerge their conflict and dissolve the stress anxiety or conflict that exists between them in other words overprotective parenting may represent a direct behavioural expression of the underlying triangulation dynamic that operates within the family similarly crossgenerational coalitions may also bring about overinvolvement and enmeshment between the allied parent and the child as the child becomes part of an alliance with one parent against the other parent interpersonal boundaries may become violated engendering overprotective and invasive parenting practices in this case as well the child becomes involved in the parental conflict which allows the family system to have the tension deflected and diffused within the system as the child is brought in between the parents the stress and tension within the system is reduced in the short run however triangulating the child through the use of overprotective practices is problematic in the long term as the family system continues to need the child to maintain its homeostasis in addition these triadic interaction patterns imply boundary violations as the child must negotiate between parents and manage conflicting loyalties this is particularly problematic during the transitional phase of adolescence where the principal developmental tasks necessitate a rebalancing of the family system and a negotiation of the rules and roles thus challenging the entire system triangulation may thus be experienced as particularly interfering and overbearing during this developmental phase and may hamper adolescents healthy development as far as we are aware however no studies have explicitly examined whether triangulation is associated with overprotective parenting during adolescence and whether this in turn is associated with adolescents maladjustment thereby we focused on adolescent anxiety as a specific indicator of adolescent maladjustment as theoretical accounts stress that dysfunctional coparenting and overprotective parenting contributes to the development of anxiety in particular the present study the overall objective of the current investigation is to put the phenomenon of overprotective parenting into a larger context by exploring whether specific coparenting dynamics are linked to parents engagement in overprotective parenting and whether overprotection in turn is linked to higher levels of adolescent anxiety we thereby made use of adolescents perceptions of coparenting and overprotective parenting as it has been argued that their perceptions and interpretations ultimately matter most for understanding how the family contributes to their development the first goal was to examine whether coparental triangulation uniquely related to more perceived overprotective parenting thereby controlling for coparental cooperation and conflict the second goal was to test a spillover hypothesis that is we examined whether coparental triangulation related to more overprotective parenting which in turn was hypothesized to be associated with more anxiety symptoms method sample and procedure our sample consisted of 174 adolescents living in the frenchspeaking part of switzerland participants ranged in age between 16 and 19 years the sample is composed of somewhat more girls than boys further the majority of our participants reported living with both biological parents whereas 19 of the participants parents were separated and 2 reported another family constellation the data were taken from a larger ongoing longitudinal study at wave 1 participating adolescents were in 9 th grade and were recruited through public schools situated in both urban and rural regions of the canton vaud the present data were taken from wave 5 participants who had agreed to participate in the longitudinal study were sent paperandpencil questionnaires at home we included all participating adolescents who had completed the questionnaires of interest for the present study through an informed consent participants were informed about the confidential treatment of their data and the voluntary nature of their participation which is in compliance with the ethical standards of the swiss society of psychology measures participants completed french versions of the questionnaires a validated french version of the coparenting questionnaire was already available the other questionnaires were translated following the recommendations of the international test commission perceived coparenting we measured adolescents perceptions of coparenting using the coparenting inventory for parents and adolescents which assesses the coparenting dimensions of triangulation cooperation and conflict specifically adolescents reported on their perceptions of the coparental relationship at the dyadic level and their perceptions of each parents contribution to the coparental relationship items were rated on a likerttype scale ranging 1 to 5 previous studies offered evidence for the reliability and validity of this measure the internal consistencies of the different subscales ranged between 77 and 93 perceived overprotective parenting adolescents reported on their perceptions of overprotective parenting using a shortened version of the multidimensional overprotective parenting scale as in previous research we wanted to assess six components of overprotective parenting the full version of the mops consists of 5 items for each component totalling 30 items a shortened version was derived using data from a nonpublished data set composed of 581 adolescents specifically we performed an exploratory factor analysis on the items of each component and we selected the two highestloading items for each component resulting in a 12item shortened version of the mops this version had a good reliability correlated strongly with the full 30item version and related to relevant variables in ways that were highly similar to the 30item version example items are my parents often intervene in things that i could actually solve myself and my parents show me the possible risks in everything i do participants indicated the degree to which they agreed with each statement using a scale ranging from 1 to 5 in the present study sample this 12item version was reliable adolescent anxiety adolescents reported upon their symptoms of anxiety making use of the generalized anxiety subscale of the screen for child anxiety related emotional disorders participants rated the 9 items of this subscale based on the severity of symptoms for the past 3 months on a 3point scale ranging from 0 to 2 the scared is an oftenused and wellvalidated questionnaire and was found to be reliable in our sample data analysis as preliminary analyses we first inspected means standard deviations and correlations between the variables of interest in addition we performed a mancova to test for differences in our study variables in terms of sex age and family structure then we examined the unique associations between overprotective parenting and the coparenting dimensions of triangulation cooperation and conflict this was done through three regression analyses focusing separately on adolescents perceptions of coparenting at the dyadic level and on their perceptions of mothers and fathers contribution to the coparenting relationship in a next step we estimated a structural equation model where triangulation predicted overprotective parenting which in turn would predict adolescent anxiety we modelled triangulation as a latent variable using the three triangulation subscales as indicators overprotective parenting and adolescent anxiety were also modelled as latent variables each represented by three separate parcels that were created through a random selection of items of the respective scales we used robust ml estimation to deal with nonnormality observed in some of our variables we evaluated model fit on the basis of a combined consideration of the comparative fit index standardized rootmeansquare residual and the rootmeansquare error of approximation a cutoff of 90 for cfi 08 for rmsea and 10 for srmr indicate a reasonable fit whereas a cfi higher than 95 rmsea below 06 and srmr lower than 08 would indicate a goodfitting model we performed all analyses in r 353 results preliminary analyses means standard deviations and correlations are presented in table 1 perceived overprotective parenting correlated significantly with all coparental dimensions with higher scores on overprotective parenting being strongly associated with more perceived triangulation and moderately associated with more perceived coparental conflict and less perceived coparental cooperation the mutual relations between the coparenting dimensions were generally significant except for the associations of perceived paternal contribution to coparental conflict with perceived paternal contribution to coparental cooperation and with perceived maternal contribution to coparental conflict and cooperation the triangulation dimensions generally related positively to the conflict dimensions and negatively to the cooperation dimensions whereas the conflict dimensions were generally negatively associated with the cooperation dimensions finally higher scores on adolescent anxiety related to significantly more perceived overprotective parenting more perceived triangulation and more perceived paternal contribution to coparental conflict the mancova testing for differences in terms of sex age and family structure indicated no significant multivariate effects for sex f main analyses we first tested for the unique associations between perceived overprotective parenting and the coparenting dimensions of cooperation conflict and triangulation through three linear regression analyses the first regression analysis focused on coparenting at the dyadic level the results are presented in table 2 and indicated that higher levels of perceived triangulation related uniquely to more perceived overprotective parenting dyadic cooperation and conflict were not uniquely associated with overprotection results are similar when focusing on adolescents perceptions of mothers contribution to the coparental relationship as can be seen in table 2 associations for maternal cooperation and conflict were nonsignificant whereas higher levels of perceived maternal triangulation related uniquely to more overprotective parenting results regarding adolescents perceptions of fathers contribution to the coparental relationship indicate no significant unique association between perceived paternal cooperation and overprotective parenting however for adolescents perceptions of fathers contribution to the coparental relationship it was found that both perceived coparental conflict and triangulation uniquely related to more parental overprotection 1 then we estimated a structural model to examine whether perceived triangulation predicted more perceived overprotective parenting which in turn would predict more adolescent anxiety we first estimated the measurement model which yielded a good fit  2 3643 p 05 cfi 98 rmsea 06 srmr 05 then we estimated the structural equation model linking coparental triangulation to adolescent anxiety through overprotective parenting the model fitted the data well  2 4375 p 05 cfi 98 rmsea 05 srmr 06 results are depicted in figure 1 and indicate that triangulation significantly predicted higher levels of overprotective parenting which in turn predicted more adolescent anxiety in addition adding a direct path from triangulation to anxiety did not ameliorate the fit significantly  2 179 p 18 cfi 001 moreover the indirect effect of triangulation on adolescent anxiety through overprotective parenting was significant as an ancillary analysis we examined whether family structure moderated the relations depicted in figure 1 using multigroup comparison analyses first we examined measurement equivalence by comparing a model with all factor loadings freely estimated with a model where the factor loadings were constrained to be equal across the two groups the multigroup comparison provided evidence for measurement equivalence δχ² 301 p 81 δcfi 003 then we tested for structural equivalence by comparing an unconstrained model with a constrained model these analyses suggest that the structural paths presented in figure 1 are not significantly different for adolescents living with their two biological parents vs adolescents from other family constellations δχ² 535 p 07 δcfi 004 discussion since a decade or so there is a striking increase in attention to the phenomenon of overprotective parenting both in the scientific and the popular literature previous research efforts documented the implications of overprotective parenting for childrens and adolescents development as well as the parentrelated and childrelated antecedents of overprotective parenting however models describing determinants of parenting underscore the importance of also looking into contextual factors for explaining why parents rely upon certain parenting practices herein we aimed to put the phenomenon of overprotective parenting into a family systems context in order to better understand the family dynamics that are associated with parental overprotection as our results show perceived triangulation in particular strongly related to more overprotective parenting which in turn predicted more anxiety symptoms among adolescents the present findings underscore the importance of understanding the phenomenon of overprotective parenting as it may appear as the symptom of a more fundamental problem in the family system indeed it seems that parents overprotection also may serve a purpose within the system by triangulating the child underlying conflicts and tensions may be diffused within the system however especially during adolescence a developmental phase necessitating the system to find a new balance this may be experienced as overbearing and may put adolescents development at risk potentially bringing about anxiety symptoms and other types of psychopathology thus these findings shed light on the broader family patterns associated with overprotective parenting and offer insight into the precise dynamics of how difficulties within the family system may be linked to adolescents anxiety symptoms these results are important from a clinical and societal point of view as well as divorce rates are elevated in our contemporary society there is an increased risk for children to feel caught between the parents where the child feels like having to side with one parent hence becoming involved in the parents conflicts in line with this our preliminary analyses indicated that adolescents from separated families perceived higher levels of triangulation as compared to adolescents living with their two biological parents these dysfunctional patterns may spill over and impact the adolescents development if left unaddressed or managed ineffectively of course it should be noted that such dynamics are not limited to youth from divorced families research suggests that children with conflicting parents may even be worse off as they continue to be confronted with these difficulties sometimes even into adulthood future research therefore could focus specifically on similarities and differences in these dynamics among families where adolescents live together with their two biological parents vs adolescents from separated families and other family constellations finally these findings are particularly relevant for clinicians working with adolescents and young adults the transition to adulthood is often challenging and potentially anxietyprovoking for youth especially in a changing society where pathways to adulthood become increasingly diversified and individualized due to globalization and socioeconomic changes when young people consult professionals as they struggle during this transitional phase it may be worthwhile zooming out in order to gain a more contextualized and fuller picture potentially the adolescents anxiety symptoms serve an underlying function that can only be understood by gaining more insight into the family systems functioning these difficulties then can be addressed either in individual sessions or through family interventions in addition although beyond the scope of this paper it may be important to further zoom out and consider macrocontextual factors as well as socioeconomic changes may also push parents to become overly involved a number of limitations should be acknowledged first the crosssectional data preclude drawing any conclusions regarding directionality in the present study adolescents anxiety symptoms are modelled as an outcome variable however anxiety symptoms may also trigger parental worries which may elicit overprotective parenting and negative coparenting 1 longitudinal research is needed to examine directionality of effects moreover we solely relied upon adolescent perceptions this is a strength as past research on coparenting rarely relies upon adolescent perceptions and as past research indicates that their perceptions and interpretations often matter most for understanding how parenting is associated to their development however recent research on overprotective parenting indicated that it is important to consider multiple perspectives for understanding the dynamics involved in overprotective parenting future research therefore should rely upon a multiinformant design multiinformant information also allows for the consideration of singleinformant bias for instance anxious adolescents may be biased in their perceptions and interpretations of parental behaviors reliance upon multiinformant information observational information or a vignettemethodology may help to take potential bias into account that is due to the singleinformant nature of the data in addition qualitative research could yield a more indepth understanding of how overprotective parenting represents a behavioural expression of underlying triangulation dynamics where interpersonal boundaries are potentially violated further our assessment of overprotective parenting did not differentiate between mothers and fathers although past research offers no evidence for differences in the implications of maternal vs paternal overprotection the present approach could obscure gendered pathways this may be particularly relevant in the context of the observation that perceived fatherdriven coparenting conflict was a unique predictor of overprotective parenting whereas this was not the case for motherdriven conflict this is fairly surprising as past research indicates that motherreported coparenting conflict is particularly predictive of youth psychosocial functioning whereas this is not so much the case for fatherreported coparenting conflict disentangling perceptions of maternal vs paternal parenting and coparenting seems essential for future research to gain a better understanding of potentially gendered pathways in a related way it is interesting for future research to also focus on links with maternal gatekeeping which is defined as a set of beliefs and behaviors that may inhibit collaborative efforts between men and women in family work and which is linked to negative coparenting and lower levels of father involvement potentially overprotective parenting practices may be a manifestation of gatekeeping dynamics within a family system and may help to explain gendered differences in overprotective parenting finally it should be noted that our study relied upon a community sample characterized by relatively low levels of coparenting conflict and triangulation and high levels of coparenting cooperation future research could focus on clinical samples in order to examine the generalizability of the documented associations despite these limitations the present study offers important insights into the coparental context in which overprotective parenting may arise throughout development triangulation in particular was found to be associated with more overprotective parenting although triangulating the adolescent may allow a family system to diffuse tension and conflict within the system our study suggest that this is problematic as these triangulation dynamics may be experienced as overprotective hence setting the adolescent at risk for anxiety symptoms table 1 means note 1 0 living with both biological parents 1 other family constellation tables figures footnotes 1 as a set of ancillary tests we repeated the initial regression analyses thereby including adolescent anxiety as an additional predictor of overprotective parenting the unique effects of adolescent anxiety on overprotective parenting were not significant and the obtained associations between coparenting and overprotection were very similar to the results documented in the paper running head coparenting and overprotection

the authors would like to thank the adolescents and parents who kindly accepted to participate in the study as well as the master thesis students and research assistants who helped in the data collection and data input the data analyzed during the current study are deposited in the fors repository and are available upon request

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introduction walking health and wellbeing besides being a protective factor for a variety of longterm conditions walking helps to improve fitness stamina mobility physical health and psychological wellbeing this applies equally well to walking in groups walking in green spaces and farmland can be especially beneficial for psychological wellbeing especially when compared to walking in urban environments walking in the countryside however can depend on opportunities shaped by social class and ethnicity and may therefore not be easily accessible to more marginalized groups walking provides opportunities for stimulation restoration contemplation and also in the case of group walks a sense of pleasure from the shared experience similar findings have been reported by svarstad in relation to different meaning constructions attached to hiking by norwegians however at the present time there does not seem to be a single theory capable of explaining links between group walks and social relations for the purpose of this paper it would make sense to combine theoretical perspectives in the search for an improved understanding of organized group walking experiences the social relations of walking in the present study three theoretical perspectives are relevant to an understanding of the social relations of group walks following geslers influential work on conceptualizing the therapeutic landscape ie the idea that setting and places can have properties conducive to health others have considered that less attention has been paid to intersubjectivity in encounters with different landscapes the argument goes that it is not so much the inherent or perceived properties of particular landscapes that matter it is how we use and make sense of them and crucially in the present case how we do so together similarly duff has suggested that therapeutic landscapes or what he terms enabling places are more closely linked with the practices or behaviors of a places inhabitants than with the inherent properties of a place these observations have echoes of middletons earlier work that illustrated the coagency of everyday environmental features and embodied movement in accounting for peoples walking experiences this makes it important to understand how people do their group walks and engage the environments in which they walk including the organizational arrangements linked to the above gatrell has proposed the notion of therapeutic mobilities the idea that movement itself can be conducive to health and wellbeing he argues that attention needs to be paid to the active body the social body and walkability presented by an area doughtys ethnographic study is to date perhaps unique in demonstrating how in a detailed and nuanced way the social dynamics of embodied movement in a walking group can be shown to have therapeutic outcomes the third theoretical perspective of relevance here concerns what happens when on a voluntary basis people come together to participate in a shared activity with voluntary and community organizations in general members appear to maintain membership on the basis of a shared identity with the group close relationships support and trust walking group studies have thus far shown evidence that group walks provide an excellent milieu in which social networks can be generated and strengthened however to date such evidence has not been critically considered against the backdrop of writing on social capital where there still remains much contested debate for bourdieu social capital is the sum of the resources both material and less tangible accruing to an individual or a group by virtue of possessing a durable network of relationships of mutual acquaintance and recognition in short it represents the stock of potential or actual resources tied to group members from the perspective of the individual the amount of social capital possessed depends on the number of network connections that can be mobilized and also the amount and types of capital possessed by others to whom the person is related in the group however bourdieu was primarily interested in discerning how social class and inequality were reproduced through access to resources available through attachment to networks for putnam on the other hand social capital is viewed as a public good residing in the shared values and mutual trust of members of a community in which interconnecting ties increase social capital in the community as a whole in contrast to bourdieu putnams main interest was in understanding the ingredients of community cohesion at the heart of this lies the assumption that the amount of social capital in a particular community has direct consequences for a multiplicity of outcomes that benefit that community and also the wider community bourdieu has social capital as being exclusive to members of the group whilst putnam argues a more expansive position in which wider civic virtue can arise from a groups activity it remains to be seen how the social relations of group walks together with the dispositions and embodied practices to which these give rise are informed by different social capital perspectives the caythorpe walking for health group the walking group was formed in january 2011 in caythorpe lincolnshire uk it is part of the national walking for health network sponsored by the ramblers and macmillan cancer support for the first three years annual average attendances for the weekly walks ranged from 1827 growing to an average of 33 by 2014 currently it is typical for over 40 people to turn out fourteen members of the group including the first author have trained as walk leaders when walkers first join the group they complete a registration form these records show that almost all the walkers selfreferred some on the recommendation of a friend although the group was established with encouragement from the local primary care practice and indeed the walks timetable is posted in the practice very few walkers have joined as a result of a referral from their general practitioner such as it is recruitment can therefore be characterized as being a product of individual volition and informal networking all but a few of the regular walkers are retirees sixty percent of the walkers are women and 40 men most have longterm health conditions or disabilities our oldest regular walker was 89 years of age at the time of interview the walking group comprises a mix of longterm residents and recent incomers to the area several members of the group bring dogs with them the walks start at the pavilion adjacent to the village playing field every monday morning available to the walking group at no charge the pavilion is an important resource in the community as it provides changing rooms space for relaxation a kitchen and a licensed bar we return there at the end of each walk for a cool down cup of tea or coffee and biscuits provided by volunteers socializing over tea and coffee has become an integral part of the walking experience the £1 charge for tea and coffee is the only direct cost borne by walkers otherwise the walks are costfree an aim has been to make walking possible for people with diverse conditions and levels of energy to make this practicable walkers divide into two groups the larger strider group follows routes of between 25 4 miles whilst the second stroller group follows shorter routes of between 1 2 miles at a more leisurely pace thirtytwo different walks have been mapped some referred to euphemistically as away walks because they involve walking from nearby villages a typical walk for either group takes about one and a quarter to one and a half hours for those in the strider group this burns roughly 300 calories per walker participants can move between the two groups when their personal circumstances change for example following surgery or recovery from ill health each group is led by two or more volunteer walk leaders in common with most if not all w4h groups the walk leaders provide briefings before each walk to welcome new walkers and to share information about landmarks and any possible hazards on the route the local terrain is predominantly open countryside and farmland embracing villages hamlets and farmsteads as well as arable land and some woodland to the east of caythorpe the land rises to expansive heaths whilst to the west it drops down towards the trent valley the area is bisected by a busy main road the walks therefore comprise three distinctive interrelated components the initial gathering and briefing the walk and the cool down in the pavilion at the end of each walk each of these organizational components becomes significant in understanding the social relations of the walking experience methodology an ethnographic approach with gg being a walk leader with the group an ethnographic enquiry was considered to be the best way to tap into the social world of the groups experience ethnography is about the study of a culture or social group by observing members behaviors and asking questions about their actions interactions and experiences over the years ethnography has shifted its focus from seeking a global understanding of a culture to exploration of more specialized topics like families or units of institutions or participants with a common identity or shared experience it is typically best accomplished through an insider perspective that is by being a member of the group or culture under study in this case gg had access to the groups history an understanding of its membership and growth regular contact with its members a close knowledge of the walks and environment and he was on first name terms with everyone a combination of participant observation analysis of documentary records and depth interviews formed the basis of this ethnography coupled with efforts to integrate and triangulate the data being a walk leader gg was able to access summary details of the walk registers that provided biographic information and details about how walkers accessed the walking group as a participant at the quarterly planning meetings of the walk leaders he was able to contribute to shared experiences of route planning walk organization safety and liaison with the local community as a regular walker he had been able to observe patterns of socializing between walkers and the assimilation of new walkers into the group for nearly four years all this crucial insider information was central to understanding how structuralorganizational elements of the walks shaped social relations between the walkers however in order to develop a deeper understanding of why people joined the group why they continued walking and what benefits they derived from the experience it was deemed necessary to interview a sample of walkers the first 19 walkers approached in late 2014 agreed to take part in confidential facetoface interviews with gg about how they understood their walking experiences there were no refusals with the interviews a maximum variation sampling approach was adopted so as to capture walkers with a diversity of personal circumstances including age gender civil status and existence of a longterm condition there were 13 women and six men age range 5889 years 13 married four widowed two divorced six of the 19 participants lived by themselves all but three participants had an identified longterm health condition or disability that resulted in restrictions to mobility loneliness or lowered selfconfidence there were 12 regular walkers in the sample and seven walk leaders men were slightly underrepresented in the sample compared to the 4060 ratio of men to women in the walking group as a whole the severity of disabilities or the life threats associated with the health conditions of participants varied enormouslyat one extreme were individuals with low back pain issues or relatively minor joint problems whilst at the other extreme were individuals with cancer or heart conditions one such person recently having had major heart surgery a number of individuals had multiple conditions posing a threat to their health independence or wellbeing assisted by prompts interviews with walkers were openended so as to make each interview resemble an ordinary conversation all interviews were taperecorded and transcribed verbatim well over 100 pages of singlespaced narrative were generated all participants gave their signed consent to take part in the study names of participants have been removed from quotes to protect anonymity analysis and integration of data insider data comprised a mixture of notes from walk leader meetings email correspondence with walk leaders and the local district council responsible for governance of w4h groups in the district documentary evidence about walker registrations and attendances and diary notes based on ggs experiences of walking with the group over a period of four years these data were used to build a picture of the growth of the walking group and its composition providing some clear indications about its reach in the community it was clear from an early stage for example that people from social housing were underrepresented with no referrals to the group coming directly from the local primary care practice walk leaders were also very conscious that people with more severe health conditions or disabilities might not be benefiting from regular walks offered by the group having walked with the group for four years gg had also accumulated a rich vein of anecdotal experience from fellow walkers about their personal health and wellness their personal networks their reasons for joining the group their connections to the community and the benefits they derived from the walks all this material was unstructured yet also compelling in providing important context about members of the group and their connections with eachother the wider community and the physical environment it was to provide important points of reference when making sense of participant interviews and in particular when seeking external affirmation of storylines relating to social relations within the group the structure of the interview was very simple there were three primary questions why did you join the walking group why did you continue walking with the group and how did you benefit from the experience the intention was to enable participants to be as free as possible to tell their stories with minimal interruption the stories were treated as narratives for as polkinghorne suggests these serve as evidence for personal meaning rather than the factual accuracy of events that have taken place transcripts were reread many times descriptive notes were made alongside chunks of text as a way of representing what each participant was seeking to convey each narrative was then reread descriptive notes included with a view to identifying overarching storylines these storylines were crossvalidated by another member of the team transcripts were then compared with eachother to confirm and strengthen the overarching storylines during interviews participants were occasionally asked to confirm what they meant so as to reduce the risk of imposing the interviewers interpretation on the participants view of the world enhancing the trustworthiness of each participants account this left an audit trail embedded within the transcripts such memberchecking more typically involves returning transcripts to participants so that they can confirm what they have said or intended to say sometimes with therapeutic benefits however in our experience few research participants read transcripts fully let alone comment on them participants were instead given a copy of a draft report and asked to comment on matters of accuracy representation and interpretation almost all of them doing so the final report can therefore be viewed as a coconstructed account ethics and governance ethical approval for the study was given by sheffield hallam university after governance arrangements had been agreed with the ramblers and macmillan cancer support results walk organization and social relations it was mentioned earlier that the walking experience comprised three discrete organizational components as will be seen these components were linked to the development of social relationships in distinctive but complementary ways initial gathering and briefing the initial gathering by the pavilion took place off road in the grounds of the village playing field providing a safe place for welcoming and briefing walkers despite the availability of timetables and booklets describing the walks every walk was preceded by a briefing from one of the walk leaders about the route to be followed and the hazards likely to be encountered briefings were regarded as crucial to the setting of safety conditions for each walk so they became readily associated with feelings of reassurance and supportiveness the walk leaders were perceived as well organized taking the recce and walk leading roles seriously it was always made clear who was leading and tailing each walk the narratives would suggest that this was associated with feelings of trust and dependability as a place and space the initial gathering and briefing acted as a catalyst for sociability and networking it was a familiar milieu that had the characteristics of an enabling place that was welcoming where affective resources and social resources were reproduced meeting up was commonly characterized as a buzz its a buzz a buzz to feel you know somebody enough to give them a hug i can think of certainly somebody in the group an older person in the group who is just adorable now i would never have met her in normal circumstances but you just look for her in the group because shes somebody to want to know i mean how good is that it was a context where upon arrival walkers began to pal up and to exchange news before the walk new walkers were always given a welcome and introduced to the rest of the group a first step towards integrating them into the group hugging in the group was not uncommon when everyone was assembling for the walks it was a feature that appeared to be without age or gender barrier some people even feigned disappointment if they did not receive a welcoming embrace from someone they had come to know well being amongst a community of friendly people was especially important to some individuals whose personal lives could be emotionally challenged for almost everyone coming to the walks provided a regular opportunity to catch up with friends and new acquaintances i think the most these experiences suggest that travelling with the person through their lives is a crucial part of walking with them the chemistry of the group was such that noone was left to themselves for very long these comments offer support for the idea of walking not only as a therapeutic practice that provides a capacity for restoration but also as something that is purposeful and carried out for the pleasure of shared experience the walk during the walks individuals frequently chose to slow down or speed up in order to walk alongside others and socialize with them changes to the walking pace were sometimes unintentional for example when avoiding rabbit holes or when minor injuries were sustained more typically pacing was affected by conditions underfoot or by the narrowing of footpaths that forced people to walk in single file natural halts whether caused by stiles gates dykes and busy roads or initiated by walk leaders created the conditions where changes in patterns of associating could take place organically when natural obstacles like streams dykes or muddy ground were encountered these presented opportunities for mutual helping and encouragement sometimes prompting satirical comment this supports doughtys finding about walking in a group being far from linear and processionalit is rather dynamic and constantly negotiated in relation to others one of the walkers captured this well if people are at the front they dont always stay at the front people sort of change throughout the walk and thats why i think its important to pause every now and again and people catch up and sort of walk off with somebody else without knowing it necessarily walks were conducive to both prolonged and short conversation periods of silence were also the acceptable as it was readily understood that people liked to contemplate their surroundings to meditate or just to be by themselves for some of the time conversations of all kinds took place during the walksfrom exchanges of a private nature geeky conversations on specialist topics where there were shared interests to more fleeting forms of dialogue about incidental matters like road conditions parish activity and the british weather information sharing when walking often led to new discoveries about the hitherto hidden identities of fellow walkers and also about community resources that people did not realize existed such seeking and sharing of information can be seen as linked to setting some necessary conditions for producing social capital for example satisfying curiosity linking into existing networks and deepening interpersonal relationships for some walkers there was a simple delight in being able to talk to anyone about just about anything but without censure and it doesnt matteryou can drop back and talk to anybodyyou talk to different people while you are walking that seems to be part of it and it doesnt matter what inanities you talk aboutnobody tells you to shut up this emancipatory quality of the group can be viewed as a manifestation of its capacity to accommodate individuals with a wide range of idiosyncratic interests it also made it easy for people new to the area of which there were several to integrate into the group to begin to form ties with other people and to form a closer attachment to the community there were frequent occasions where feelings of mutual concern for fellow walkers developed into something tangible the first of these was active caregiving through getting together we get to know people and then theres the caring bit having quite a serious operation flat on her back and everybody is combining together by sending good wishes or going to visit which is lovely how life should be quite often walkers spoke to personal experience of being on the receiving end of expressions of care from members of the group same as one week i caught my foot on a bramble and i sort of fell i managed to protect myself and the following week said to me are you ok with that fall you had and i said fine i said its just something stupid i did and you think well people are caring for you and that monday morning when i was getting ready for the walk but with chest pains i ended up in hospital for the rest of the day i had quite a number of walking people phoning up to find out how i was so you find thats all part of the social side these two examples indicate that the walks enabled people not only to share lifes challenges but also to monitor the wellness of fellow walkers and support them when it may be necessary also noticeable was a widespread awareness of the capacity for care and empathy of the walking group as a whole i think we are aware if a member of the group had had a problem you usually see before the end that somebodys walking with them or if youre going up a bit of an incline you usually find theres somebody with themwithout anybody being asked to do it i think it is a caring group such evidences of active caregiving extended well beyond the confines of the walk reaching more directly into the homes of fellow walkers for example one walker had made a decision to undertake a barn conversion but during the early stages of taking down the existing old barn to make way for the ground works he became ill another of the walkers stepped in with a friend and completed much of the demolition work as a goodwill gesture to a friend in need a more common experience was the attentiveness of the whole group to the absences of regular walkers if the absence was unexpected it usually led to someone making a making a mobile phone call or home visit to check on the missing persons welfare such monitoring at a distance suggests the existence of an efficient bush telegraph within the walking group reflecting a stock of collective knowledge and goodwill and a capacity to enact reciprocities for the benefit of group members though the walks provided for fleeting forms of conversation they also offered opportunities for closeness and intimacy people sought out friends in whom they needed to confide or they made a beeline to people with whom they shared interests it was rare for the group to walk as one unit more usually people walked in twos and threes so that ordinary conversation was manageable within a group of 40 there could be 1520 conversations going on at any one time being led the walks enabled walkers to be free of having to work out directions or to be unduly concerned about safety issues enabling them to focus on socializing or on enjoying the sensory experience dogs were frequent catalysts for socializing during the walks supporting findings about the links between dogwalking and sense of community typically their antics were a source of fun and enjoyment there were temporary disappearances for example when two of the terrier dogs headed into rapeseed fields their movements obscured by wavering rapeseed blossoms the main attraction to a hyperactive spaniel was water so puddles and muddy dykes provided him with the opportunity for a bath much to everyones amusement except his owner events such as these merely reinforced affective ties between walkers walkers could be so wrapped up in conversations with each other that they often failed to take in the surroundings leading some to berate themselves for doing so one thing i have noticed because youre walking with a group and you might be engrossed in conversation with somebody else i dont always take notice of where im going we get so far and i think now drat how did we get here because im not going to remember later by contrast those walking in the stroller group were much more environmentally aware this heightened environmental awareness was linked to the gentler pace of the stroller group and more frequent stops as well as personality factors we old people in the stroller group we have a healthy interest in beauty and nature and we dont feel we have to race because we only go half the distance of the main group we have leisure to stop and look and appreciate and thats part of the wonder of it this closer identification with place was not the sole preserve of the stroller group other walkers noted affective changes in themselves and others when encountering new places or staring out over vistas three elements to such environmental attraction were evident in the narrativesthe appreciation of natural beauty discovery of new places and an identification with places that had special meaning for individuals however the active contemplation involved usually required a pause from walking or a degree of quiet in order to reset the senses when these conditions were present it was as if the very notions of time and place were stretched the stories people shared nevertheless show that there is a real dilemma here for the walking grouphow to satisfy the needs of those who wish to walk at pace with an eye on their pedometers and caloriebusting targets against those who simply want to go for a stroll and soak up nature though the splitting of the strider and stroller groups was a nod in this direction it was far from being the complete solution this tension is not new some years ago copeltons study of a hospitalsponsored walking group reported that older walkers resisted using pedometers because they felt that using them interfered with socializing besides helping to make people feel better about their personal health and wellbeing something we discuss in more detail elsewhere the walks were a great source of fun and enjoyment largely because of the pull of being among a group of welcoming people this turned out to be key to understanding why people kept coming back for more week after week in short it was integral to the very sustainability of the group and to its growing significance as a valuable resource in the community i also walk because i enjoy the people i mean you cant get on with everybody but you gravitate to certain people and i look forward to going and meeting those people as well as the walking also noticeable among the oldest walkers and more generally among those who lived alone was the view that the walks gave them something useful to do by filling up spaces in their diaries as part of a desire to stay active and healthy in short it helped them to feel energized as well as socially connected cool down in the pavilion the scope for community integration provided by socializing during the walks was complemented by opportunities for relaxation when walkers returned to the pavilion for tea and coffee the pavilion provided a context where walkers were not only looked after by volunteers who laid on hot drinks and biscuits it also enabled people to regroup to meet people they had missed on the walk or to consolidate fleeting conversations it was not unusual for people to make announcements about local events taking place that needed support and there were also regular appeals for charitable fundraising these information exchanges were qualitatively different from those that took place during the walks as a physically contained space the pavilion helped to consolidate the reproduction of affective social and material resources within the group physically it was a refuge from the elements it provided amenities that became indispensable to the group toilets a place to change out of wet clothing showers heating and comfortable seating though not part of the walking group volunteers laid on teacoffee and biscuits that were always prepared so as to coincide with people returning at the end of each walk the pavilion ladies providing this voluntary help had longterm conditions themselves or had previously worked in healthrelated occupations so there were mutual empathies that ran deeply between them and the walkers i think it the usual rules governing use of the pavilion were relaxed to allow walkers to bring in their dogs it had become something of a standing joke that one of our canine friends always looked forward to the malted milk biscuits on offer hobnobs apparently did not have the same appeal such accommodations were much appreciated and served to strengthen the inclusive character of the group over refreshments more relaxed conversation was possible earlier more fleeting conversations on the walks could be consolidated sometimes resulting in what might be termed community building for example one of the walkers had become aware that some of the older men in the village were feeling isolated following bereavement or because their spouses were out at womens institute or craft club meetings quite a lot he therefore decided to do something about it by becoming involved in setting up an activityinterest group the caythorpe league of gentlemen for the support of older men clogs remains alive and well two years later besides being a physical refuge the pavilion can therefore be seen as a haven where lots of lighthearted banter information exchange debate planning confiding healing relaxation and community building took place as such it fulfilled important functions that were complementary to those served by walking itself walks strengthening of social relations and sustainability whilst it has been shown how social relations were generated by and through the walking group it is also important to consider evidence for sustainability fortunately a number of indicators of sustainability were evident first walkers kept coming back for more walks as shown by the growth in numbers secondly almost all those interviewed said that a key factor in their decision to continue walking with the group was the sheer fun and enjoyment of the experience much of this being tied to opportunities for socializing or for fostering new or deepened friendships with fellow walkers something also noted by copelton thirdly structural properties of the walking group were conducive to the replenishment of social capitalthe local accessibility of the walks their regularity the accommodation of people with a wide spectrum of longterm health conditions or disabilities the absence of any direct costs or charges for being part of the group the knowledge that safety factors for each of the walks had been addressed and finally acknowledgment that the walks were led by trained people who carried the necessary accoutrements further evidence for the links between walkability and social capital can be found in rogers gardner carlson one of the walkers neatly captured sentiments expressed by many others suggesting that the walks had become an indispensable part of weekly routines concluding remarks the main findings offer some links to theories about the emergence and strengthening of social relations within a walking group in regard to the therapeutic landscape or enabling places the findings suggest that the idea of place is instrumental to any understanding of walkers experiences in creating new spaces and affordances the walks offered fresh personal and social opportunities for walkers new loci for linking bridging and bonding strengthened friendships and support mutual monitoring of health and wellbeing practical support and help with personal growth in the present study the organizational elements of the walkthe briefing the walk and the pavilion cool downeach gave rise to examples of embodied interaction that had value for walkers in the fostering maintenance and consolidation of social relations these three elements were synergistic in the sense that their sum was greater than each of their parts it would now seem inconceivable to start a walk without a welcome and briefing or to end a walk without winding down in the pavilion by sharing a cup of tea or coffee these experiences and the expectations surrounding them have now become well and truly socially and culturally embedded supporting carpenter and green following doughty it is also evident that social resources were developed and strengthened during the walks arising from the ability of walkers to exercise freedom about their choice of walking partner to renegotiate these arrangements whilst on the move or to decide whether to walk alone for a while this meant that there were opportunities for solitude and reflection as well as for many types of bridging and bonding behavior this cementing of social relations went far beyond the walk itself and extended into reciprocities between walkers in wider familial and social contexts despite most participants stating that their primary motivations for walking were healthrelated their reasons for continuing with the walks were mainly to do with fun and enjoyment of the company of fellow walkers exemplifying the ways in which health and social relations are deeply intertwined however all participants reported benefits to their health energy stamina and wellbeing as a result of coming on the walks with the walks being locally accessible to those involved regular and perceived as safe walkability was good another factor relevant to walkability was the fact that the walks were guided this meant that walkers did not have to invest energy into working out where to walk they could instead focus on contemplating their surroundings socializing or perhaps even enjoying solitude and private space these findings suggest support for gatrells ideas about therapeutic mobility in which the active body the social body and the walkability of an area are all central to understanding how people benefit from walking but importantly in this instance why they keep coming back for more to what extent do the findings suggest support for social capital theorizing as a social network the group made it possible for people to engage oneanother on a variety of levels that aided the feeling of inclusivenessconversations could be variously fleeting incidental intensive confidential therapeutic geeky or liberating evidence of affective ties that were generated suggested that the group gave rise to considerable bonding capital reciprocities were expressed in practical and instrumental as well as social forms through the walking group aided by strong feelings of trust and dependability all of these evidences being manifestations of the groups cohesiveness coupled with the evidence presented about the sustainability of these experiences this can be seen as a considerable relational achievement of the group in these senses there was support for the positions taken by both bourdieu and putnam however central to putnams view of social capital were evidences of bridging capital that can be seen as adding to wider civic virtue examples from the present study would include the walking groups role in enabling another community organization clogs to come into being the growing popularity of the walking group as a community resource for volunteers and its role in helping other organizations with their fundraising and charity work even through its modest £1 charges for tea and coffee at the end of each walk the walking group contributed around £1400 net per annum directly into the coffers of the playing field committee to help in defraying the costs of maintaining the pavilion although at face value a modest amount as a form of economic capital it was highly prized by community leaders including parish councilors responsible for maintaining the viability and usefulness of the pavilion as a resource to the community it is tempting to suggest that the commonality of experiences expressed in these ways placed in the hands of the group more forms of capital upon which to draw than they would otherwise have had implications for practice and future research there appear to be persistent challenges of adherence experienced by older and disabled people in relation to their involvement with physical activity programs schemes like walking for health may provide important clues about elements of sustainability that are translatable to other types of physical activity this is likely to require a shift from traditional biomedically rooted programs that focus on motivational factors as the route to explaining adherence and sustainability to programs that emphasize enjoyment social relationships and opportunities to contribute different forms of capital to others this is very much in line with the proposal made by kinnafick thøgersenntoumani duda following their qualitative study of a walking intervention that increasing opportunities for enjoyment might increase the likelihood of adherence and wellbeing however despite the healthy pattern of walker recruitment and retention there remain concerns among the walk leaders that the groups reach in the community remains limited with people from social housing and people with more serious illnesses or severe disabilities very much underrepresented unless something can be done to enhance outreach by walking groups there is a danger that inequalities in the health and wellbeing status of different social groups might be deepened many w4h groups are the product of a community development approach where over time they become more or less autonomous with much of their success dependent on voluntarism especially in the form of walk leaders it is difficult to see how improved outreach and inclusion can be achieved without closer involvement with primary health services and social care agencies for example in relation to referral pathways and routine monitoring of more vulnerable individuals whether such inclusion can be achieved without changing the culture of w4h groups and avoiding risks of colonization by formal agencies remains to be seen the study findings are selfevidently placebound caythorpe and environs are not typical of all rural areas of the uk and the local community is not representative of the nations population with regard to socioeconomic status income migration and ethnicity other research has found that for groups like lowincome mothers living in deprived communities walking may simply be a reminder of the daily pressures they face so the motivations and rewards they experience may be quite different from those reported here there are also indications that walking for health initiatives may not be available in areas that most need them in the present study the narratives did not include people outside the walking group like family doctors nurses or local community leaders who may have taken a different view of the group and its links to wider civic virtue in particular indeed claims about civic virtue ideally need to be authenticated by reference to other groups and communities of interest in the locality this study reports on a relatively homogenous cultural group within britain but many people living in the uk belong to a superdiversity of different cultural traditions for whom access to and use of the natural environment exploring local geography and the enjoyment of nature and convivial company may also be important in a study of polish migrants to the uk horolets found that some participants strategies of familiarization involved a process of walking and getting lost until the individual found local features which they recognized research on leisure activities such as walking amongst migrant groups is sparse but may be affected by many complex factors such as perceptions of standing out as a racial group in environments which are traditionally associated with britishness and the availability of time and income finally it is important to bear in mind that theoretically and in terms of robust testing social capital remains a work in progress critics of putnam like portes or carpiano for example take issue with the assumptions about causal links between individual capital and civic virtue it is also argued that the very factors that allow groups to cohere like the walking group in the present studybut particularly the rules and norms governing the behavior of its membersmay well be the same factors that deter others from participating for example within the caythorpe walking group people from social housing are underrepresented so factors beyond local accessibility are operating to exclude them whether this is linked to the norms and values underpinning the operation of the walking group remains an open question in the language of bourdieu such rules and norms can represent an opportunity for some but a constraint for others for tzanakis social capital is by nature a resource that is both contextand timerelative more social capital does not always mean better at least not for everyone involved in any case longitudinal designs are needed so as to trace prospectively causal links between the experiences of walkers emergent social relations and evidences of social capital preferably using tighter conceptual designs of the type suggested by carpiano declaration of interests there were no conflicts of interest for any of the authors the research did not receive any specific grant from funding sources in the public private or notforprofit sectors

it is already well established that regular walks are conducive to health and wellbeing this paper considers the production of social relations of regular organized weekly group walks for older people it is based on an ethnographic study of a walking for health group in a rural area of the united kingdom different types of social relations are identified arising from the walk experience the social relations generated are seen to be shaped by organizational factors that are constitutive of the walks the resulting culture having implications for the sustainability of the experience since there appears to be no single uniting theory linking group walk experiences to the production of social relations at this time the findings are considered against therapeutic landscape therapeutic mobility and social capital theorizing finally implications for the continuance of walking schemes for older people and for further research are considered

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d epression in older adults is strongly associated with being house bound and isolated which may lead to a decline in physical and cognitive function and eventually to premature death physical activity which is a modifiable behavior can prevent or alleviate depressive symptoms in older individuals in particular group participation in sports may have positive effects of physical activity and social participation on mental health leading to enjoyment enhanced selfesteem and decreased stress increasing the frequency of sports group participation may alleviate the worsening depressive symptoms among older individuals who walk at an even rate compared with those who increase their daily walking time participation in a sports group may also lower the risk of functional disability compared with participation in other kinds of social activities therefore growing evidence suggests that sports group participation may have preventive effects on psychological and physical functional decline in older individuals the definition of social participation mostly focuses on a persons involvement in activities that provide interaction with others in society or the community and is an index of social capital there has been an increasing application of social capital in public health according to putnam social capital refers to features of social organization such as trust norms and networks that can improve the efficacy of society by facilitating coordinated actions it is also described as resources that are accessed by individuals as a result of their membership of a network or a group social capital has two levels individual level which refers to resources accessed by the individual through their egocentered networks and group level which pertains to a characteristic of the whole social network findings among studies investigating the relationship between group level social capital or social participation and older individuals mental health were inconsistent although communitylevel bonding social capital and bridging social capital do not necessarily improve mental health in older individuals saito and colleagues revealed that a composite score of communitylevel social participation had a protective relationship for individuallevel poor selfrated health and depressive symptoms in older individuals after adjusting for individuallevel social participation inconsistent with this study communitylevel formal group participation did not correlate with older depressed individuals symptoms in another study with small samples there is little evidence to support an association between communitylevel sports group participation and depressive symptoms in older individuals the present study investigated whether older individuals living in community areas with a higher prevalence of sports group participation among older individuals are less likely to have depressive symptoms compared with those living in community areas with a lower prevalence of such participation after controlling for individuallevel sports group participation we performed communityand individuallevel multilevel analyses to clarify the contextual relationship between communitylevel sports group participation and depressive symptoms in older individuals methods study sample we used crosssectional data from the japan gerontological evaluation study the jages project is an ongoing cohort study investigating social and behavioral factors related to the loss of health with respect to functional decline or cognitive impairment among individuals 65 yr or older between august 2010 and january 2012 a total of 169215 communitydwelling people 65 yr or older were randomly selected from 31 municipalities including metropolitan urbansemiurban and rural communities in 12 prefectures from as far north as hokkaido and as far south as okinawa in japan and were mailed a set of questionnaires overall 112123 people participated we used data from 74681 respondents in 516 community areas after excluding 46 community areas with e30 respondents each 4099 respondents whose areas of residence were unknown and 32363 respondents whose status of sex age depressive symptoms or extent of sports group participation were unknown one community area was essentially equivalent to one elementary or junior high school district generally a school district represents a geographical scale in which the japanese elderly can travel easily by foot or bicycle therefore the present study used the community area as a proxy for the neighborhoods of people in our sample jages participants were informed that participation in the study was voluntary and that completing and returning the questionnaire via mail indicated their consent to participate in the study ethical approval for the study was obtained from the ethics committee at nihon fukushi university japan dependent variable we assessed depressive symptoms using the 15item geriatric depression scale following previous research mild or severe depressive symptoms were set as an outcome of the present study cronbachs for internal consistency of the scale was 080 and the cutoff point was previously validated as a screening instrument for major depressive disorder with 96 sensitivity and 95 specificity communityand individuallevel independent variables participants were queried on their frequency of sports group participation possible answers were q4 diwk j1 23 diwk j1 1 diwk j1 13 dimonth j1 a few times a year or zero we defined participating 1 dimonth j1 or more often as participation in a sports group and aggregated individuallevel sports group participation by community area as a communitylevel independent variable previous research indicates that the correlation of the proportion of older individuals with depressive symptoms in areas with communitylevel sports group participation 1 dimonth j1 or more often tended to be strong compared with that with communitylevel sports group participation 1 diwk j1 or more often covariates sex was controlled by conducting a stratified analysis age groups were categorized as 6569 7074 7579 8084 and q85 yr to gather information on disease status in treatment participants were asked if they were currently receiving any medical treatment answer choices were yes and no participants were asked about household members living with and were categorized as living with others or living alone drinking status smoking status and education were classified by each answer choice annual equivalent income was calculated by dividing household income by the square root of the number of household members and categorized into three groups g2000000 20000003999999 or q4000000 yen if participants did not respond to the individuallevel covariates corresponding observations were assigned to missing categories as a communitylevel covariate we calculated population density per square kilometer of inhabitable area for each community area and categorized into quartile categories statistical analysis descriptive statistics were used to characterize the participants and community areas in the data set 35975 men and 38706 women were nested in 516 community areas having depressive symptoms was the outcome variable and after adjusting for individualand communitylevel covariates the effect of communitylevel sports groups was inferred to examine the contextual relationship of communitylevel prevalence of sports group participation to individuallevel depressive symptoms we applied twolevel multilevel poisson regression analysis with random intercepts and fixed slopes and calculated the multilevel prevalence ratio and 95 confidence interval because percentages of individuals with depressive symptoms were 910 adjusted odds ratio derived from logistic regression can no longer approximate the pr two models of analysis were used both communityand individuallevel sports group participation and crosslevel interaction terms were included in model 1 in model 2 all individualand communitylevel covariates were added the pr and 95 ci of communitylevel sports group participation were estimated by 10 of participation proportion we used stata 13se for all statistical analyses results of 74681 analytic samples 17420 had depressive symptoms and 16915 participated in a sports group 1 dimonth j1 or more often when the proportions of depressive symptoms and sports group participation were calculated for each community area the ranges were 00 606 and 00 565 respectively tables 1 and2 show the descriptive statistics and crude pr for having depressive symptoms for the individualand communitylevel variables by sex respectively participants of both sexes with older age who had disease under treatment lived alone were past drinkers or were pastcurrent smokers were more likely to have depressive symptoms participants of both sexes who were current drinkers with higher educational levels and higher equivalent incomes were less likely to have depressive symptoms compared with male and female participants who lived in community areas with first quartile of population density those who lived in areas with the second and fourth quartiles as well as female participants who lived in areas with the third quartile were less likely to have depressive symptoms mean proportions of sports group participants by population density categories were 189 256 262 and 260 from the first second third and fourth quartiles of population density respectively table 3 shows the results of the multilevel poisson regression analyses regardless of whether the model included covariates and sex communitylevel higher prevalence of sports group participation had a statistically significant relationship with lower likelihood of depressive symptoms female pr 096 in the fully adjusted model estimated by 10 of participation proportion individuallevel sports group participation also had a significant relationship with low likelihood of depressive symptoms female pr 058 in the fully adjusted model we found statistically significant crosslevel interaction terms in male participants only in the fully adjusted model discussion to the best of our knowledge this is the first study to find the contextual relationship between communitylevel prevalence of sports group participation in older individuals and depressive symptoms in older individuals a 10 increase in communitylevel sports group participation was associated with an 11 and 4 reduction in the prevalence of depressive symptoms after adjusting for individuallevel sports group participation and covariates not all older individuals are able to participate in a sports group because of factors such as work lower socioeconomic status or less social support furthermore not all of those individuals are physically active because of demographic and biological psychosocial behavioral social and cultural and environmental factors the results of the present study suggested that promoting sports groups in a community may be effective for the prevention of depression not only in sports group participants but also in nonparticipants having those barriers the individuallevel relationship between sports group participation and mental health in adults has been frequently discussed in previous reports a systematic review indicated consistent evidence that cluband teambased sports participation when compared with individual forms of physical activity was associated with improved psychological and social health on the basis of a 6yr longitudinal study using nationally representative data in japan adults 5059 yr old who participated in exercise or sports activities were less likely to have worse mental health compared with those who did not participate in the current study we also found an individuallevel preventive relationship of sports group participation with depressive symptoms in older individuals the reciprocals of the pr for participating in a sports group were 179 in male and 172 in women male sports group participation may mitigate the adverse effects of living alone on depressive symptoms in women sports group participation may help in overcoming the adverse effects of disease status in treatment and smoking furthermore it is worth noting that the mitigational relationship of 10 increases in communitylevel sports group participation which were estimated by the reciprocals of the pr was comparable with the agerelated differences by 15 yr in men and 10 yr in women among fundamental dimensions of social capital the previous report suggested that communitylevel social participation was more closely related to older individuals depressive symptoms than was social cohesion and reciprocity in that study communitylevel social participation was evaluated by merging sports group volunteer group and hobby activity participation those groups with egalitarian relationships could be categorized as horizontal social capital and had a stronger contextual association with individuals health status than were groups with hierarchical relationships even when extracting sports group participation in the present study we found that the protective relationship with mental health remained social contagion informal social control and collective efficacy are regarded as pathways from grouplevel social capital to individuallevel health outcomes social contagion references the notion that behaviors spread more quickly through a tightly knit social network sometimes the behavior that spreads via the network can promote healthy lifestyle changes that is the spread of smoking cessation informal social control refers to the ability of adults in a community to maintain social order that is to step in and intervene when they witness deviant behavior in relation to the present study some older individuals may be encouraged by sports group participants to get more exercise or take up a sport irrespective of whether it is an individual or a teambased sport collective efficacy is the grouplevel analog of the concept of selfefficacy and refers to the ability of the collective to mobilize to undertake collective action facilities systems bylaws for health promotion or sports business and management may develop to reflect the opinions and actions of communities with many sports groups and participants grouplevel mechanisms of widespread sports group participation may result in positive spillover effects in the present study a statistically significant crosslevel interaction term was observed in men only suggesting that male sports group participants living in community areas with a higher prevalence of sports group participation might be less likely to have depressive symptoms compared with those living in community areas with a lower prevalence of sports group participation one of the possible benefits in group sports is the opportunity to play key roles in those groups takagi and colleagues reported that japanese older men who held group leadership positions reported lower depressive symptoms than those who participated but did not have leadership roles however this interaction effect did not apply to women because japanese society is characterized by strong patriarchal values men seek meaning and identity by being valued in the workplace male retirees may feel rewarded by seeking positions of authority or responsibility within the social organizations in which they participate it is assumed that a community with many sports group participants naturally also has many sports groups accordingly leadership positions for managing such groups are necessary therefore older male participants who live in an active area with sports groups may have opportunities to fill these key roles the strength of the present study is its large nationwide populationbased sample enabling sexstratified communityand individuallevel multilevel analysis for clarifying the contextual relationship of sports group participation however the study has several limitations first reverse causality could occur because of the nature of the crosssectional design and further longitudinal studies are needed to resolve this limitation second the response rate and the valid response rate were 663 and 441 respectively therefore selection bias may have affected the results several missing values may also bring systematic bias in our previous study we reported that both response rates and percentage of sports group participants with lower incomes were significantly lower than those in participants with higher incomes furthermore respondents with unknown status of depressive symptoms or extent of sports group participation reported lower equivalent income compared with valid respondents in our survey the present study showed that respondents with lower income tended to have depressive symptoms therefore nonrespondents or respondents who were excluded from the analysis might have worse depressive symptoms and be less likely to participate in sports groups compared with valid respondents although the results showed a significant relationship of sports group participation with depressive symptoms this slightly low valid response rate might attenuate the relationship third we could not discuss the preferable frequency of sports group participation because we set the cutoff point for participationnonparticipation to only one time point 1 dimonth j1 or more oftenless than 1 dimonth j1 although we attempted an analysis in which the cutoff was set to 1 diwk j1 or more oftenless than 1 diwk j1 the models did not converge however we believe at least 1 dimonth j1 to be an adequate and feasible frequency for both individuals who are not familiar with sports and those who want to establish a leadership position and manage a sports group in their community conclusions older individuals living in community areas with a higher prevalence of sports group participation in older individuals are less likely to have depressive symptoms compared with those living in a community area with lower prevalence of participation after adjusting for individuallevel sports group participation and other covariates that is we found a contextual preventive relationship between communitylevel sports group participation and depressive symptoms in older individuals furthermore the benefit may favor male sports group participants promoting sports groups in a community may be effective as a populationbased strategy for the preventing depression in older individuals regardless of each individuals participation status

purpose communitylevel group participation is a structural aspect of social capital that may have a contextual influence on an individuals health herein we sought to investigate a contextual relationship between communitylevel prevalence of sports group participation and depressive symptoms in older individuals methods we used data from the 2010 japan gerontological evaluation study a populationbased crosssectional study of individuals 65 yr or older without longterm care needs in japan overall 74681 participants in 516 communities were analyzed depressive symptoms were diagnosed as a 15item geriatric depression scale score of q5 participation in a sports group 1 dimonth j1 or more often was defined as participation for this study we applied twolevel multilevel poisson regression analysis stratified by sex calculated prevalence ratios pr and 95 confidence intervals ci results overall 17420 individuals 233 had depressive symptoms and 16915 226 participated in a sports group higher prevalence of communitylevel sports group participation had a statistically significant relationship with a lower likelihood of depressive symptoms male pr 089 95 ci 085092 female pr 096 95 ci 092099 estimated by 10 of participation proportion after adjusting for individuallevel sports group participation age diseases family form alcohol smoking education equivalent income and population density we found statistically significant crosslevel interaction terms in male participants only pr 086 95 ci 077095 conclusions we found a contextual preventive relationship between communitylevel sports group participation and depressive symptoms in older individuals therefore promoting sports groups in a community may be effective as a populationbased strategy for the prevention of depression in older individuals furthermore the benefit may favor male sports group participants

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introduction the middleaged population is thought to be at their time of maturation while the elderly are thought to be in their terminal phases of life these stages denote the end of childrearing the development and transmission of cultural norms and values to succeeding generations as well as the understanding and consideration of the meaning of life in light of the wealth of knowledge and experience accumulated 1 this is the stage in life when the concept of life satisfaction comes into the picture it is also the time when various factors such as family dynamics and marriage start affecting the mental health of an individual let us discuss these in relation to our study of married individuals in istanbul demographic aspects of istanbul in istanbul in the past five years the middleaged and elderly have made up 219 of the population and they are aging at the fastest rate in the world the patriarchal family structure and regard for elders also continue to play significant roles in istanbul society the situation of the older and middleaged population who have seen the effects of industrialization and modernization is also problematic istanbuls population has been showing an increasing trend since 2020 reaching approximately 15 million in 2022 which has increased by 143 from 2021 most of the senior generations resources and efforts were directed toward their offspring and the advancement of society 2 the concept of life satisfaction one of the key measures of quality of life is life satisfaction which is defined as a cognitive and judging process and a thorough assessment of the human quality of life life satisfaction in the middle and later years along with mood and psychological wellbeing can be seen as a major indicator of successfully adapting to the aging process according to medley life satisfaction is an attitude and a subjective sensation of contentment and fulfillment over ones entire life additionally he asserted that to feel content and happy with life before old age and to lead a life that is socially desirable in old age the idea of successful aging is one that is meticulously fashioned by each persons ideas and selfconcepts over the course of a significant period of time 3 family dynamics and marriage family and family values have an overall impact on peoples lives both directly and indirectly the psychological wellbeing of a couple increases with how well they get along 4 and life satisfaction rises with the quality of a parentchild connection 5 academics generally concur that challenging personal experiences are a significant contributor to the global growth of depression in women 6 marriage is one of the most important socially destructive factors in any society on earth and research has shown that it is associated with problems with womens mental health like depression 7 previous studies looked at whether negative marital events including emotional and sexual infidelity and the possibility of divorce led to psychological problems like depression when taking into consideration the likelihood of marital conflict the issue is still controversial and open to debate despite the numerous studies that have been done in the past to specifically explore this area although the information has been gathered from numerous nations and people many questions remain unanswered marriage and divorce may be considered culturally dangerous 6 in the current situation it is crucial to comprehend how this complex issue will affect istanbuls culture and to create new approaches to dealing with complex phenomena the findings from the aforementioned studies imply that a thorough investigation of the problem of marital satisfaction in istanbul is necessary examining and comprehending the implications associated with infidelity calls for a significant undertaking that accounts for the cultural complexity of istanbul only a few earlier studies were able to relate the problem to womens violence and marital satisfaction in istanbul 8 contributing factors of depression high levels of attachment depression set apart preoccupied and anxious attachment types high attachment depression sufferers frequently doubt their partners commitment to the relationship and exhibit sensitive emotions when they are rejected 9 in addition to having sensitive emotions people with high attachment depression struggle to process their negative feelings and use coping mechanisms when faced with psychologically stressful situations 10 individuals with high depression then experience relational discomfort that is increased due to their impaired ability to control the negative affect 11 it was also found that depression and certain life events such as marriage style education and having children were associated not only can marriage style education and having children affect the association between depression and life satisfaction but they also have an impact on it 12 similar earlier studies showed that women who had experienced their husbands infidelity or threats to leave the marriage were six times more likely to be diagnosed with significant depression and anxiety than those who had not 13 it was interesting to learn that individuals who divorced their relationships due to infidelity suffered from low selfesteem fury low confidence loss of trust and social isolation 8 the results of multiple earlier studies demonstrate a significant correlation between stress and infidelity previous studies findings suggested that unfaithful couples were more disturbed and worried than faithful ones finally the researchers noted while focusing on depression and solitude that the main source of stress that results in psychological suffering is loneliness 14 similar research showed that 75 of persons who felt lonely believed that depressive symptoms were to blame for their loneliness 15 previous research has shown that compared to other divorces infidelityrelated separations usually leave divorced individuals more predisposed to stress additionally this study clarified that marriage style having children and education cause psychological issues similar research conducted in the past discovered that women are more likely than their male spouses to experience stress and depression the present study sets out to determine the underlying effects of two theoretically sound but previously unpackaged elements on the psychological adjustment of married couples and divorcees our goal is to understand the factors that prevent someone from becoming mentally healthy so the idea is to understand what factors in their life lead to depression so we can work on preventing it for future generations in this paper we seek to understand the effect of marriage style having children and attaining education on the prevalence of depression among married individuals living in istanbul materials and methods the articles research methodology is described in this section we go into every step we take to create our models in complete detail including the data we use sample training and testing and sample evaluation the statistical analysis was conducted using the anaconda 32019 package and ibm spss version 21 objectives do factors like gender education working status marriage style and status of having a child relate to the prevalence of depression in married individuals in istanbul hypothesis h1 there is a significant relationship between the occurrence of depression and factors such as gender education working status marriage style and status of having a child in married couples h2 there is no significant relationship between the occurrence of depression and factors such as gender education working status marriage style and status of having a child in married couples research design the study was a crosssectional study using quantitative methods it included independent variables including the marriage style the status of having a child and education and the dependent variable depression for the purpose of this study we defined education as the act of teaching or learning general knowledge honing ones thinking and judgment skills and overall intellectually preparing oneself or others for a mature life also we operationally thought of depression as major depressive disorder or depression that is a prevalent and dangerous medical condition which has an adverse effect on ones emotions thoughts and behavior sadness andor a loss of interest in previously pleasurable activities are major symptoms of depression sample the study included 433 subjects from istanbul and the details are mentioned further in the article as the population is finite but large in number convenience sampling was adopted for the study there are several approaches to determine the sample size these include a census of small populations imitating a sample size of similar studies using published tables and applying formulae to calculate a sample size for populations that are large cochran developed the equation given below n 0 here n 0 is the sample size z 2 is the abscissa of the normal curve that cuts off an area at the tails e is the desired level of precision p is the estimated proportion of an attribute that is present in the population and q is 1p the value of z is found in statistical tables which contain the area under the normal curve in this study we presume that population size is finite and unknown the formula was applied to know the sample size and the sample size was 433 search strategy and article selection our study was based on articles from sciencedirect search terms included mental health married couples and depression we modified the phrase prognosis to prediction after analyzing the initial batch of publications to find more papers that were pertinent based on the title and abstract we only read the language that was pertinent to the study these data were taken because istanbul has a high rate of depression when examining married people the data were taken only among married individuals in this study we examined the connection between married individuals moods and potential prognoses agespecific information was not included in this study instead a subgroup of participants was examined 16 study area and participants the samples were taken from istanbul the dataset included 433 participants records our focus was on examining the existence of depression on married individuals in istanbul and their risk factors data acquisition the kaggle database was used to collect the data 17 and this investigation was carried out the procedure explains how data are produced the database is being set up for modeling in this step data about depression among married couples in istanbul are taken as original datasets from kaggles websites the database records served as the foundation for the implementation of every component all demographic traits are related to these traits observations with missing values were then entirely subtracted from the features that had been chosen information from both structured and unstructured text statements was combined with the data the forecast model was developed using a classification algorithm that forecasts hidden data since information about medical appointments was not included our focus was on how depression developed in married couples descriptive analysis the dataset included records of 433 participants who were all from istanbul the details from the descriptive analysis are shown in figure 1 note all scales in the current study had satisfactory cronbachs alpha coefficients beck depression inventory the beck depression inventory is a 21item selfreport rating inventory that measures characteristic attitudes and symptoms of depression 18 the bdi has been developed in different forms the bdi takes approximately 10 minutes to complete although clients require a fifth to sixthgrade reading level to adequately understand the questions the 21 categories are given in the appendix they are referred to as b1 to b21 in this paper 18 the mean standard deviation maximum and minimum of depression in married couples bdi scores are shown in table 1 beck depression correlation heatmap heatmap is utilized to display the correlation between features of a dataset the performance of the correlation heatmap is shown in figure 2 the correlation between characteristics is calculated using pearson correlation and the formula is given below where i and j denote vector cov denotes covariance of i and j and var and var denote standard deviation of i and j the correlation coefficient has a value range of 1 to 1 the stronger the correlation between the two vectors the higher the correlation coefficient the data are structured in the form of a heatmap in which the percentage of truly classified events is shown in the light color and the percentage of incorrectly classified events in the dark color understanding the effects of the features included in the best model for depression in married couples by explaining the effectiveness of the best model there is a strong correlation between education gender the status of having a child marriage style and working status that is the correlation between working status and gender is 039 the correlation between education and the status of having a child is 022 and the correlation between marriage style and the status of having a child is 023 performance comparison between the model summary of the regression analysis for regression analysis the dependent variable is depression and the independent variables are the marriage style status of having a child types of working and education the r r square adjusted r square and standard error of the estimate were calculated to compare the groups of depression in married couples that were gender education working status marriage style and status of having a child for study participants of the istanbul population and are shown in performance comparison between anova of the regression analysis in table 3 the anova values are compared between the three groups in five demographic categories where the significant value is less than 005 so here all five groups selected have significant values anova performance comparison between significant coefficients of the regression analysis based on the regression model we determined the coefficient value and its associated significance level for each predictor the variables b1 to b21 refer to the 21 categories in the bdi the coefficient of significance value for each gender group is compared in according to these findings there was no statistically significant difference between the gender groups for a significance value greater than 005 in table 5 the education groups coefficient of significance is compared with some significant values in all variables according to the findings the education groups difference was not statistically significant when the significant value was more than 005 the working status groups coefficient of significance is compared in table 6 with some significant values for all variables thus a significant value smaller than 005 is chosen in this instance according to the findings there was no significant difference between the working status group as the significant value is larger than 005 in table 7 the marriage style groups coefficient of significant value is compared with some significant values being less than 005 in all variables thus a significant value smaller than 005 is chosen in this instance according to the findings there was no discernible difference between the marriage type group and the significant value was more than 005 table 8 compares the coefficient of significance among the groups of people who report having children where some significant values are less than 005 for all variables thus a significant value smaller than 005 is chosen in this instance according to the findings there was no statistically significant difference between the status of having a children group when the significant value was larger than 005 unstandardized coefficients unstandardized coefficients unstandardized coefficients unstandardized coefficients machine learning application to predict depression in married couples the machine learning model is a representation illustrating the development process 19 we used two ml approaches for categorization the decision tree and random forest to pinpoint the crucial factors linked to depression in married couples this model was chosen to be implemented in this study because it gives the highest accuracy value decision tree a dt is a flowchart that resembles a tree and creates a binary tree the dt method works best for the classification issue a dt is a supervised learning technique which means that the data used to build the tree already knows the solutions the level of classification accuracy reached on the training dataset and the size of the tree have the biggest effects on the models ability to predict marital sadness an innovative technique for building classification models from a set of training data is the dt algorithm to create dt architectures topdown layered dividing and conquering strategies are employed the framework includes training data modeling for nodes and branches the root node which is the first node divides up each bit of data until a termination condition is satisfied the root node internal node and leaf node are the three structural components that make up the dt the leaf node the end node completes the dt whereas the internal node indicates the qualities that are contained within the tree the dt terminating criteria say that all samples for a particular node belong to the same type of class and that there are no residual attributes for further splitting there are many distinct types of dt but the most wellknown ones are information gain gini index and gain ratio a dt can be produced using the algorithms id3 j48 c45 and c50 the most wellknown algorithms are those in c50 the decision rule was cut down and the dt was made more compact using the pruning technique 20 random forest as part of the ensemble learning model the classification technique known as rf combines predictions from inferior classifiers it builds an indicator ensemble out of dts that are growing according to discrete ensemble parameters in a data subspace that is randomly chosen 21 it produces exceptionally accurate predictions can handle a huge number of input variables without overfitting and is rapid and easy to use making a variety of trees that will each help in casting a vote for a specific class is the first step of the procedure to cast a vote the training data must be divided into smaller equal subsets before a dt is created the tree is built using the rf algorithm in the data collection let x represent the number of classes and y represent the number of variables the tree node is evaluated using the input variable y with a value for the y variable that is picked at random determine the best split for each tree node the tree is finally fully grown and no longer requires pruning a new sample is projected when the tree is uprooted at the terminal node the label is given to the training sample the rf forecast is then observed after several iterations of this procedure across all trees 22 performance assessment where the percentage of times the classifier successfully identified a positive sample as positive is expressed as true positives the percentage of times the classifier correctly identified a negative sample as negative is known as true negatives false positive describes the frequency with which a negative sample was mistakenly classified as a positive sample by the classifier false negative refers to the frequency with which a positive sample was incorrectly categorized as a negative by the model the efficiency and efficacy of the faster dt and rf model were assessed for both the testing and validation sets using the accuracy recall precision and f1 score model assessment to more accurately evaluate model performance and minimize any potential deviation between the estimations we employed fiverepeated fivefold crossvalidation the data are split into two subsets using this technique training and test data the model is developed using the training data and assessed using the test dataset the entire performance indices such as precision recall f1 score support and accuracy are created using the performance estimations from five iterative crossvalidations it is important to keep in mind that the ratio of cases to controls in each subset remained unchanged each subgroup gave an accurate picture of the state of the larger community as well as the main sample two sets of testing and training sets of data were created the data were split into two distinct situations the train and test sets being respectively 70 and 30 for situation 1 and 80 and 20 for situation 2 we have shared the results for situation 1 below table 9 shows the results of the prediction of depression in married couples using the rf model we can observe that the classifiers predicted depression with an accuracy of around 60 and an f1 score of around 75 precision and recall range between 60 and 83 furthermore the table reveals that the performance of the classifiers is almost similar in terms of predicting depression model table 9 results of the prediction of depression in married couples using the random forest model table 10 shows the results of the prediction of depression in married couples using the dt model we can observe that the classifiers predicted depression with an accuracy of around 80 and an f1 score of around 85 precision and recall range between 72 and 96 furthermore the table reveals that the performance of the classifiers is almost similar in terms of predicting depression model results table 9 demonstrates the results when the rf technique is used for predicting depression among married couples f1 score accounts for 75 of the total number of different approaches precision accounts for 60 accuracy of rf accounts for 60 and recall accounts for 825 table 10 demonstrates the results when the dt technique is used for predicting depression among married couples f1 score accounts for 85 of the total number of different approaches precision accounts for 72 accuracy of dt accounts for 80 and recall accounts for 96 finally tables 9 10 demonstrate that dt is 20 more accurate than rf models regarding h1 which is supported by the current study it claims that there is a significant relationship between the occurrence of depression and factors such as gender education working status marriage style and status of having a child in married couples according to the findings presented in tables 910 depression among married couples was positively correlated with factors such as gender education working status marriage style and status of having a child regarding h2 which is not supported by the current study it claims that there is no significant relationship between the occurrence of depression and gender education working status marriage style and status of having a child in married couples according to the findings presented in tables 45678 depression among married couples was positively correlated with factors such as gender education working status marriage style and status of having a child discussion the goal of the current study is to research the moderating effects of gender education employment position marital status and status of having children on the development of depressive married couples the findings presented in tables 45678showed that factors such as gender education working status marriage style and status of having a child were moderators of melancholy among married couples the results of the present study support some of those of earlier ones 2324 also some previous research showed that divorced people had higher levels of anxiety stress and depression than married people additionally previous studies have demonstrated that married women with solid relationships with their husbands and families were less likely to have psychological issues like stress anger anxiety loneliness and depression 25 however other studies found that after having a divorce from their partners women were more likely to commit emotional and sexual adultery 2627 finally it was also indicated by the researchers that loneliness is the major cause of ones stress which causes psychological distress while examining isolation and depression in particular 28 similar studies found that 75 of persons feeling isolation believed that it was a result of depressive symptoms 29 depression in the elderly is often accompanied by other health problems or life events and most of the depressive symptoms are considered a natural reaction due to aging and are often neglected or overlooked depression in middle age and old age tends to consist of more depressive symptoms as the number of health problems increases and life events that cause depression include job loss retirement death of a spouse divorce and loss of economic power 30 strengths firstly the study demonstrates the use of ml techniques to analyze the data and predict depression in married individuals this is not used commonly in the medical literature this paves the way for future research that can apply ml techniques to predict the occurrence of a medical condition and proactively provide the best possible medical care to the patients secondly our study also has a reasonably large sample size which adds to the reliability of the study the results of the study are a valuable addition to medical literature limitations our study has the following limitations first we were only able to conduct the study in istanbul where the available sample group was too small to represent all married individuals in istanbul second this study could not identify the impact of other diseases implications of the study researchers and clinicians have not yet developed any strict guidelines for preventing depression and more research is needed to eradicate this societal ill this study could aid psychologists in predicting the occurrence of depression and reducing the effects of depression the studys findings should emphasize the females the results of the study may help clinicians work on the root causes of unhappiness before it results in divorce and depression the study attempted to emphasize the factor of depression in married couples by concentrating on the factors that contribute to depression and the solutions available future studies may be further aided conclusions the finding of this current study illustrates that compared to married couples individuals with marriage styles and who have a child have more psychological problems the results of this study elaborate that compared to arranged married couples people who do love marriage are more prone to psychological problems also the result clearly shows that depression is more common in females than males the findings indicate that when sadness is either mental or physical unemployed people are more depressed than married couples the findings also indicate that single students experience depression at a higher rate than married people it is believed that this study would aid future researchers in examining some of the subjects unexplored facets it is hoped that this study will enable future researchers to explore some more unidentified aspects of the subject appendices becks depression inventory sociodemographic details are to be filled by all participants and include the details mentioned in 1 i feel sad much of the time 2 i am sad all the time 3 i am so sad or unhappy that i cant stand it 2 pessimism 0 i am not discouraged about my future 1 i feel more discouraged about my future than i used to be 2 i do not expect things to work out for me 3 i feel my future is hopeless and will only get worse 1 i dont enjoy things as much as i used to 2 i get very little pleasure from the things i used to enjoy 3 i cant get any pleasure from the things i used to enjoy 1 i feel more restless or wound up than usual 2 i am so restless or agitated that its hard to stay still 3 i am so restless or agitated that i have to keep moving or doing something 12 loss of interest 0 i have not lost interest in other people or activities 1 i am less interested in other people or things than before 2 i have lost most of my interest in other people or things 3 its hard to get interested in anything 13 indecisiveness 0 i make decisions about as well as ever 1 i find it more difficult to make decisions than usual 2 i have much greater difficulty in making decisions than i used to 3 i have trouble making any decisions 14 worthlessness 0 i do not feel i am worthless 1 i dont consider myself as worthwhile and useful as i used to 2 i feel more worthless as compared to other people 3 i feel utterly worthless 15 loss of energy 0 i have as much energy as ever 1 i have less energy than i used to have 2 i dont have enough energy to do very much b i wake up one to two hours early and cant get back to sleep 17 irritability 0 i am no more irritable than usual 1 i am more irritable than usual 2 i am much more irritable than usual 3 i am irritable all the time 18 changes in appetite 0 i have not experienced any change in my appetite 1 a my appetite is somewhat less than usual b my appetite is somewhat greater than usual 2 a my appetite is much less than before b my appetite is much greater than usual 1 i am less interested in sex than i used to be 2 i am much less interested in sex now 3 i have lost interest in sex completely scoring the beck depression inventory after you have completed the questionnaire add up the score for each of the 21 questions the following table indicates the relationship between total score and level of depression according to the beck depression inventory

there are multiple studies that indicate that the psychological wellbeing of a couple and their life satisfaction depend on the family and society various factors such as family family values marriage style married life and education have a great impact on peoples lives both directly and indirectly it is important to understand the effects of these factors on married individuals lives that lead to depression so that appropriate measures can be taken for its preventionthis research aims to find the relationship of depressive symptoms among married individuals with various factors such as their marriage style education and having childrenthe study included 433 married individuals from istanbul who met the criteria for depression the early identification and prediction of depression in married individuals have been demonstrated to benefit significantly from machine learning techniques in this study we used decision tree dt and random forest rf predictive modeling techniques to create a model to predict the occurrence of depression among married individualsthe accuracy of the dt approach was found to be 80 and the rf approach was 60 our results showed that as compared to conventional statistical methods machine learning models performed better for classifying couplesfuture support systems that employ a range of data sources to identify individuals who are extremely susceptible to developing depression among married people may be developed using these effective models

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introduction the music ecosystem has a close relationship with various elements within it such as individual artists objective and subjective views idealistic elements and other speculative matters powhida illustrates the music ecosystem by positioning itself outside of global capitalism not as an agency but as a delusion how to place artists as social activists in their ecosystem as part of a struggle in wider arena the music ecosystem refers to the conditions that allow music to thrive in a community as well as the positive and negative impact it has the music ecosystem is involved with the music industry as well as the role of music in communities such as education celebration religion and health recovery this includes increasing understanding of music as a career option so that music truly has functional value inequality is one factor that unites all music ecosystems where the music market is frequently separated from educational strata resulting in low incomes for musicians there are no labor regulations for musicians and there is demographic discrimination music ecosystems frequently ignore longterm forms of holistic investment to support music in their communities music as an ecosystem should be viewed as more than just music but also as a form of investment whether in education copyright or broadband market access an ecosystem is a complex system made up of many interdependent agents in the world of art emergence growth complex interdependence evolution webs and networks convergence and fragility are seven ecological elements that frequently appear in an art ecosystem including music systemic holden uses these ecosystem elements to trace the movement of money ideas and products as well as the roles of subjects within them holdens perspective can provide a comprehensive overview of how art works within a social structure dealing with economic and social aspects through the logic of marketbased industrial needs the music ecosystem also considers relationships outside of the economy and seeks to identify agents and their roles in the arena the fluid nature of music makes it an easy commodity to judge in the cultural industry where music is seen as a medium for expressing identity criticism and resistance to the industry itself ecological music broadens the field of music culture and environmental studies music ecology awareness allows for exploration and adaptation to various changes to sustain musical culture agents in the music performance ecosystem can work together cooperatively creatively and innovatively in other words digitalization is the use of digital technology to change business models and provide new revenue and valuegenerating opportunities as stated on the website of the gartner company digitalization is the use of digital technology to change business models for revenue and new opportunities to gain profits through digital businesses beyond digitalization digital information technology is being used to completely transform business processes evaluate reengineer and reorganize as a result digitalization is strongly intertwined to digitalization if digitalization is the conversion of data and processes then transformation is the result of digitalization digitalization entails more than just digitizing existing data it also includes the ability of digital technologies to collect data establish trends and make better business decisions digitalization seems to have an impact on changes such as transitioning from modern to postmodern intensifying the globalization process and transitioning from the industrial to postindustrial eras based on information the next step is to switch from centralization to decentralization as part of the technology culture the broadcasting industry began to change from analog to digital but digital was more significant in terms of scale however physical processes miniaturization bandwidth and physical access remain constraints to digitalization the next change is interactivity which allows users to directly change the image or text they are watching while the term arena refers to pierre bourdieus theory of the cultural production arena it also refers to a network or configuration of objective relations between objectively defined positions in the presence and determination of agents or institutions in the structure of power distribution which directs access to specific profits at risk bourdieu defines the literary arena as one of the social arenas that is related to other arenas through an influence relationship the literary arena according to bourdieu is an independent social universe with its own laws of functioning regarding the functioning of its members its specific power relations dominating and being dominated and so onin other words discussing the literary arena entails observing literary works produced by a specific social universe with specific institutions and laws ecosystems cannot benefit agents unless they interact with other forms of capital it takes capital of knowledge skills and creativity of agents for the value of inspiration to contribute to the welfare of agents capital is also required in the form of infrastructure tools or whatever else is required to introduce creativity into social capital based on a cultural background that facilitates cooperation and communication in this sense it would also apply to the tarlingmusic ecosystem adaptive tarlingmusic has undergone numerous transformations in terms of production distribution and consumption as a result of digitalization technological transformation has two consequences there are those who feel disadvantaged but there are also those who benefit from the new model that emerges from technological development the presence of digital platforms in the form of social media such as tarling has an impact on the music industry this can be seen in the aggressive activities carried out by music labels demonstrating the enormous potential extracted from the digital platform music fans prefer video streaming services because they can find the songs they want without having to register or pay and they can do so from their laptops cellphones or tablets the more often a music video is watched and the more advertisements appear in it the more revenue it generates for record labels the phenomenon of changes in the production distribution and consumption of tarlingmusic in the digitalization arena cannot be separated from the social aspect in which artists exist in their interactions with the environment the tarlingmusic ecosystem from an ecomusicological standpoint includes the acoustics of the performance environment as well as musical interactions and sociocultural resonance in the cirebon and indramayu areas the music ecosystem helps in the identification and separation of specific issues as a result of the transition in performance from traditional to more modern modes of operation tarlings music ecosystem which is undergoing digital transformation is influenced by musicians such as songwriters instrument players and all those involved in the music group not only is the figure of a singer or sinden who became the icon of the tarlingmusic group but other agents involved in it namely the tarlingproducers managers and singers the adaptation of technological devices and the use of digital space have a significant impact on the way an agent works tarlingmusic ecosystem refers to a network that includes a value chain and a development environment known as a nurturance environment tarlingmusic has been linked to the transition from classical to modern since its inception material and methods this research uses a qualitative methodology with a case study approach in which the researcher conducts an empirical analysis to investigate realworld phenomena if the phenomenon and context boundaries are not clearly visible and there are multiple sources of evidence available qualitative data also refers to the history of phenomena that occur in the tarlingmusic ecosystem as seen through the lens of tarlings evolution from its original conception to its current digital era this study used data collection to map the tarlingmusic ecosystem the data is then qualitatively analyzed and transformed into a series of representations that include various field notes interviews conversations photos recordings and personal notes researchers attempt to interpret phenomena in terms of meanings derived from the research area this study approaches the subject of tarlingmusic from two perspectives the ecomusicological perspective and the cultural production arena perspective these two perspectives are required to investigate the tarlingecosystem in the digitalization arena which includes production distribution and consumption aspects results and discussion tarling is a popular type of music in west javas northern coastal area particularly in the indramayu and cirebon areas tarlingis associated with the guitar instrument and the flute as well as the phrase yen wis mlatar gage eling supali kasim observed that tarlingfirst appeared around 1930 in kepandean village indramayu districtregency there was a dutch commissioner at the time who asked a local resident named sakim to repair his guitar sugra son of sakim then studied lasmiyatis notes and was able to synchronize the notes in the gamelan with the guitar strings sugra then conducted an experiment by transferring the gamelans pentatonic notes to guitar strings with a diatonic tone as a result the songs of dermayonan and cerbonan which are usually accompanied by gamelan can be improved by guitar strumming the beauty is enhanced further when the guitar strings are accompanied by a lilting bamboo flute around the 1930s the strains of guitar and bamboo flute that presented dermayonan and cerbonan music became popular people from various remote villages in indramayu and cirebon accept tarlingas a lifestyle tarlings occurrence cannot be separated from the evolution of culture in indramayu according to agung nugrohos observations the cimanuk port which separates the coastal estuary from residential areas serves as a cultural acculturation center traders from china arabia india and europe stopped at the port of cimanuk at the time they usually stay for an indefinite period of time depending on the weather and wind direction that aids their journey in their spare time the traders enjoy playing various musical instruments for example portuguese traders played the keroncong with guitar instruments such as the frorengan guitar monica guitar and jitera guitar this keroncong art will also become the national art of indonesia along with the portuguese the dutch had tonel art which was used to entertain the dutch soldiers their presence at the port of cimanuk left an art trail the art that exists today is the result of a historical process of hybrid culture berokan dombret genjrin g umbul jidur macapat jointly ronggeng ketul rudat sampyong plays sintren tayuban mask dance trebang wayang golek cepak and tarlingare the arts that demonstrate the history of acculturation at cimanuk harbor tarlingis an art form derived from the words guitar and flute tarlingrefers to the fusion of two musical instruments according to another note tarlingfigures in indramayu are classified as pioneer figures and developer figures sugra was the forefather of tarling and jayana was a key figure in its development this karangampel indramayu native is an accomplished guitarist tarling has grown in popularity among young people since the 1940s that was the birth of the classic tarling the second stage of tarlingdevelopment is distinguished by a change in the songs tempo if the classic tarlingpreviously had a slightly slower rhythm the tarlingwas made more pop with a slightly faster duration tarling the third phase usually develops with the approach of dangdut songs some are remixes while others are pop or rock since the 1980s not only guitars and flutes have been used but also modern musical instruments such as saxophones drums drums and others another note from supali kasim the problems of life spilled onto the stage through guitar strumming flute strains classical songs pop songs and dramas in the appreciation of togetherness the social gap between farm laborers and employers or slaves and fishing bosses are united tarling as a traditional theater places the audience in close proximity tarlingfrequently involves the audience in spontaneous drama performances such as the jakarta art of lenong or ludruk in east java a dramaturgy combination capable of absorbing the audience tarlings music ecosystem which is undergoing a digital transformation is influenced by musicians such as songwriters instrument players and everyone else involved in the music group not only is the figure of the singer who became the tarlingmusic groups icon but other agents involved in it namely tarlings producers managers and singers the adaptation of technological devices and the use of digital space have a significant impact on how an agent works tarlingmusic ecosystem refers to a network that includes a value chain and its development environment tarlingmusic has been linked to the process of transition from classical to modern since its inception tarling ecosystem tarling is a trend that is liked and popular often found in jondol or ranggon young people like to play it this musical art began to be loved in 1935 the strains of tarling music were also equipped with a soap box which served as a drum and a jug as a gong then in 1936 the strains of tarling were complemented by other musical instruments in the form of a basin and a small ketipung that functioned as percussion sugra and his friends are often invited to perform at celebration parties even without fee usually the stage is just a mat lit by petromak lights it didnt stop there sugra also completed the tarling performance with a drama performance as for the drama that he delivered it was about the daily life that occurs in the community according to law sunaryas book abdul adjib and tarling putra sangkala the next tarling developed in response to societies and market dynamics tarling music enters the net of todays industry after transitioning from traditional music to pop popular culture tarling as a populist art form grows and develops without any standard or other standard provisions in the 1930s the sugra generation in indramayu experimented with transforming the sound of european guitar strings into the pentatonic notes of the dermayucerbon gamelan tarling is produced when the sound is combined with a bamboo flute and gamelan songs such as dermayonan bendrong or cirebon pegot tarling was introduced as a pithy show by the jayana and raden sulam generations in the 1950s with the tarling display family celebrations become more meaningful humor plays family dramas classic songs and popular songs inspired societys aesthetics tarling has evolved to songs that resemble pop but retain the basic tone of regional classics since the 1960s with the abandonment of regional classics the dynamics shifted more and more this influence has also had an impact on tarling songs with classical basic tones on popdangdut songs since the 1980s when rhoma irama became a separate ism that carried a mixture of malay indian and rock music tarling ecosystem develops according to the dynamics of society and the market from traditional music to pop tarling music then enters the net of todays industry pop culture as a form of populist art the art of tarling grows and develops without any standard or other standard provisions the sugra generation in indramayu in the 1930s experimented with changing the sound of european guitar strings into the pentatonic notes of the dermayucerbon gamelan coupled with bamboo flutes and gamelan songs such as dermayonan bendrong or cirebon pegot these sounds give birth to the art of guitarflute from another reference nurdin m noer through his notes entitled cirebon music from tradition to pop in sunaryo tarling was born in the postindependence period which is around 1945 initially this art was part of the personal art of the northern coast communitys habit of seducing girls or widows tarling classic music figure 1 ecosystem of tarling classic music at that time his songs are improvised spontaneous and just the way it is in the tarling song the important thing is that the artist is able to convey a message of love to the opposite sex nurdin m noer believes that the main source of tarling music is the cirebon tradition centered on the palace gamelan namely the sekaten gamelan this gamelan is an annual ritual music that is held every week before the night of pelal the night of the birth of the prophet muhammad gamelan sekaten is the property of the palace from this sekaten gamelan then created renteng and its partner jaran lumping dance which is maintained by many people on the other hand modern musical tarling is created by summarizing gamelan in one musical instrument namely the guitar while the flute is used as a musical complement in the next period the tarling was changed in the form of kiseran thats when the cirebon peoples opera appeared one of the famous kissers including the story of saedah and saenih followed by a story packed with a mix of tarling songs if the tarling in the indramayu area is known as the ayu city melody the tarling in the cirebon area was previously known as the shrimp city melody and the name tarling was only inaugurated when radio republik indonesia frequently broadcasted this type of music and the daily government agency inaugurated the name tarling as the official name for the type of music on august 17 1962 tarling acts as a magnet bringing together singers and audiences who freely interact with one another the typical scene is when the singer performs his song on stage and the audience joins in on the dance while giving saweran refers to the process of cultural production in which cultural products are created transformed and disseminated through the formation of consumer culture where has the music ecosystem in indramayu and cirebon evolved from the past to the present tarling art that is linked to other arts in terms of instruments and lyrics is included for example jawokan panyandra and paribasa may be considered less dynamic tarling song lyric in the past had more nuances of wangsalan and parikan which were more popular in the community the dynamics also occur in the themes and song titles which are easy to follow the trend examining the process of cultural production in tarling art as it is built and negotiated by cultural agents through the interaction of symbolic models and sensory experiences as well as concurrent meaning systems in which cultural actors are involved no surprise then that in the 1960s and 1970s tarling art performances tended to use poetic language to express social problems great love and the fate of the poor this is in contrast to the 1980s and 1990s when these themes were expressed in a direct outspoken and bombastic manner it is possible that the single organ is now regarded as a metamorphosis of the art of tarling by retaining characteristics of the local language in the songs which are frequently regarded as tarling songs dangdut with characters who continue to follow fashion trends according to pierre bourdieus theory of the arena of cultural production the arena of cultural production in music is formed from the structure of the arena of production distribution and consumption in which there are positions of individuals or actors agents who perpetuate tarling as a cultural product tarling music in this context is a cultural production arena with positions for individuals or agents who create cultural products according to bourdieus thinking individuals and society are reciprocal in the sense that the objective structure of culture and individual subjective representations are dialectically intertwined influencing and intertwining in practice as a result of these circumstances humans created tarling as a cultural product tarling has cultural influences that influence agents in their daily lives tarling is the result of cultural production that is constructed and reconstructed by the agents who participate in it tarling is the result of artists from indramayu and cirebon redesigning or constructing gamelan traditions into guitars and flutes tarling was tempted to collaborate with dangdut pop music and even rock when he first entered the recording industry as a product of a dynamic culture tarling shifted away from the acronym guitar and flute as the musical instruments that inspired it appearing more dynamic and open to the presence of other musical instruments its no surprise that tarling is also known as dangdut cirebonan tarling songs employ dangdut rhythms while retaining the cirebon language tarling music quickly gained popularity as a result of the traditional function of gamelan and wayang sounds in the cirebon area also performing tarling music is difficult because they must modify both traditions tarling players on the other hand are generally very skilled and creative in many ways changing new forms from old ones while maintaining the artistic integrity of the flute and the singers vocal style finally tarling has modified the gamelan tradition that developed in central java and parts of sunda around cirebon while still paying attention to local values and modern tastes so that tarling is more appealing according to contemporary standards meanwhile the gamelan tradition is still thought to represent values in accordance with its standards tarling ecosystem in the digitalization arena tarling in the digitalization arena is no longer seen as a musical art that has a grip both in terms of song character and performance commodity fetishism occurs due to the strong influence of capitalism practices thus forcing tarling as a cultural product out of its grip because it sees business opportunities on the grounds of market share the influence of intrinsic values in tarling music which is often associated with the presence of classical tarling music agents as filters for industrial products makes capitalists restless and look for loopholes to dominate economically by creating new production formulations the use of loopholes through the packaging route has given rise to its own production method in the tarling music industry that takes advantage of the digitalization arena people who are spectators of tarling music feel a false pleasure through performing tarling which is no longer packaged through a stage that is seen directly but is packaged and collaborated with multimedia techniques in such a way audio visual products that are spread through cyberspace and social media platforms offer symbols of cultural industry products the enjoyment that the audience gets is actually from a new product that has its own value the audience no longer thinks and is proud because of their desire to watch the tarling concert stage but rather the symbol and brand of the concert which is considered to have prestigious and labeled values classical music is considered to have details that make it different from one another and can evoke a sense of community individuality this happened to tarling music at the beginning of its emergence in the 19701980s where tarling still limited itself to liberality because it still paid attention to standards both in terms of production and consumption tarling dangdut or dangdut cirebonan referring to adornos view could be the will of capitalist agents who want to manipulate peoples musical tastes seeing the huge market potential in culture makes capitalist agents tempted to recreate a very profitable market with the community as a living asset while simultaneously suppressing its competitors namely culture that acts as a filter for society against capitalist domination tarling music seems to be no longer valued as an intellectual work that can be enjoyed and studied but becomes an industrial product that acts only as entertainment when tired and in free time tarlings appearance is far from traditional classical or ancient music tarling music agents in indramayu and cirebons north coast are now primarily using information technology to popularize tarling tarlings popularity is of course influenced by the popularity of the tarling group and its singers music production is constantly changing as a result of digitalization and social media platforms for performing tarling music the venue in the form of a stage is no longer dominant there is no longer any need to bother with preparing the stage as an entertainment arena and tarling music can be produced reproduced and even consumed in a variety of ways in addition to utilizing the digitalization process and social media platforms tarling music can be watched via live broadcasts on instagram facebook and youtube the performance of agents in the digitalization arena includes the production subarena distribution subarena and consumption subarena that are all intrinsically tied to the old classic ecosystem and must be adapted to the new modern ecosystem where there is a transition from analog to digital performance tarlings music ecosystem also preserves old agents with classical and modern periodization the meeting point of classical and modern tarling cannot be eliminated because their relationships are still intertwined agents from different generations are equally connected in the arena even if agents from modern tarling musicians appear to be dominant in the digital space tarling music ecosystem explains the existence and role of agents for their performance in the digitalization arena as shown in the following scheme the music ecosystem in the above schematic also shows that the subareas of production distribution and consumption have networks outside of their performance areas for example there are street tarling singers classical tarling artists newly emerging tarling music groups new fans publishers a paid music agency and a production house that frequently becomes a partner or business relationship with a music group the presence of these agents in the digitalization arena has an impact on how traditional music is produced transformed and consumed regional characteristics influence the way and performance of agents in the ecosystem as part of their ecosystem in the social space the process of production distribution and consumption of tarling music which is done conventionally on a macro basis from a political economy perspective leads to excessive profit panning for the industry and if viewed from adornos perspective in the end it only benefits those who play with capitalist principles it is the market rulers who are dominant in many cultural industries of course in this case music is also one of the biggest parts technological developments also have a very significant impact on the music industry the cheaper and easier it is for the recording and editing process of course is a decisive factor that now recording can be done anywhere including the development which is quite extreme for indie musicians with the term bedroom musician where they feel apart from limited funds they also feel more comfortable to compose songs and carry out the recording and distribution process in private spaces such as rooms media is an influential channel in the distribution of global culture which directly influences changes in peoples lifestyles and makes people as consumers of a culture if people have become consumers of a new culture it is likely that there will be changes to the culture that exists in that society this is reinforced by the assumption that the media are often used as a tool for community change one of the web sitebased features that can form a network and allow people to interact in a community is social media on social media people can carry out various forms of exchange collaborate and get to know each other in the form of visual and audiovisual writing such as twitter facebook instagram youtube and others social media provides an opportunity to interact more closely with consumers can be a medium to form an online community social media can be part of an overall emarketing strategy combined with other social media tarling music ecosystem in production subarena the ecosystem in the production subarea perceives how tarling music is produced from its conception to its development process and how it is influenced by technological advances that bring digital devices the transition from analog to digital devices had an impact on the system and the workings of tarling music production digitalization also resulted in a new habit of producing tarling music the preproduction stage is the recording planning stage throughout that all materials to be produced are determined this stage typically includes song selection instrument planning and then the production process which includes overdubbing and involves a number of people including songwriters musicians technicians and producers all of whom contribute creatively 2016 tarling music digitalisation is a challenge for them as they produce songs by setting up their own production equipment and processing the songs to create digital music files they are gradually adapting to how the digital music files they have created can be distributed and viewed by their fans causing in financial gains and popularity the practice of digitizing tarling music has an impact on the ecosystem of the production subarena particularly the migration of contemporary recording practices from commercial facilities to smaller ones as demonstrated by the independently carried out digitizing in mini studios the mini studio as part of the tarling music ecosystem supports the idea that music production is becoming easier for a small community of artists as well as the music group themselves each music group can simply work collaboratively from within itself to achieve a common goal of producing music creatively and independently they can also work directly in the technologybased music distribution industry independent touring bands have the potential to change their habits by becoming successful small business owners tarling s music ecosystem in the production subarena cannot be separated from the aesthetic role of an independent producer in fact many of the producers of the tarling music group are free to make many choices of individual creativity related to ideas and intrinsic values despite having to deal with largescale music production they eventually got used to simplify the way of production which can be done through a mini studio they even make their bedrooms or living rooms look like studios equipped with production equipment such as computerslaptops cameras and other devices connected to the internet the production process considers how the production results can be used as product materials that can be marketed via the internetbased digital space as a result most tarling music groups distribution system goes through several technically distinct stages including preproduction production and postproduction tarlings music production already relies on an independent production pattern that is carried out without involving the role of the producer actor and management from the agency or outside party members of the tarling group due to its position as an independent music industry when compared to the previous era when recorded music had to be done through recording company agents such as major labels the practice of recording independent music is presumed to be more convenient the practice of digitizing is believed to make production work easier and certainly benefits the tarling groups musicians because they dont have to spend so much money the transformation process or distribution system for tarlings musical works becomes easier not only when producing recordings but also because the music produced is in the form of digital files that can be converted into digital files with various file formats these digital music files are used as raw materials or content to be distributed on digital platforms via existing social media because of the freedom to experiment with new creativity technological advancements and the ease of production methods affect the stages of tarling music production the creative process which has been stifled by record labels frequently leads musicians to choose independent paths as their platform for expressing their ideals through music it is difficult for music producers to adapt to a new ecosystem with the various changes that occur in the world of regional genre music the presence of music digitalization is a choice that forces music producers to abandon the old ecosystem of producing tarling music tarling artists will never again be pursued by capital city music producers who offer invitations to record in the studio for a fee of rp 5 million to rp 6 million rupiah they also no longer discuss the high cost of producing a video clip which can only be produced by a wellknown production house which can be calculated for a single album production of at least six to twelve songs not to mention the copyright issues that only record labels face tarling artists no longer have to return to the recording studio several times just to obtain a few copies of cassette tapes which are then converted into compact discs the existence of production houses and live streaming services for example is the dominant party in the tarling music ecosystem which is also starting to feel the impact of the analog to digital transformation because their presence thrives in the digital era the phenomenon of production houses cannot be separated from the tarling music ecosystem content creators are spreading despite various constraints but they are pressured to adapt to digital devices in fact they occasionally use their home as a ministudio to create tarling music they produce video recordings of every tarling music event organized by residents who hold celebrations such as weddings even at social events such as school reunions independence day celebrations and regional birthday celebrations tarling ecosystem within the distribution subarena the ecosystem in music subdistribution is how to transform tarling music digital files distribution is intertwined to how tarling music consumers listen to or obtain digital music materials digital music files can be viewed and accessed through portable devices and computers making them more versatile because they can be easily transformed through devices and do not require physical storage space the internet has altered the traditional music industrys value chain converting music storage from cassettes to mp3s is part of the online digital music classification digital music files free record labels and distributors from traditional music distribution chains allowing artists and fans to connect directly via websites and peertopeer technology digital downloads have an impact on the overall music product particularly independent singles with a longer storage the reason for this is that digital downloads are sold through separate channels when vinyl single songs were in their heyday they were frequently used to sell albums albums can be considered as a platform for earning money indirectly from single songs mp3 is a very popular audio format the invention of this digital file has contributed greatly to the development of digital music available online although now various digital music formats are increasingly sophisticated mp3 seems to have not been completely eroded this is due to the fact that mp3 files can be directly played on a personal computer or portable digital music player such as the apple ipod or converted to a compact disc publishers who target international fans by distributing tarling music through paid music selling apps such as spotify and joox those who are indonesian migrant workers in general are willing to listen to music by downloading it on a paid app to meet the quality standards desired by publishers or online digital file music sales services the song must be packaged in such a way through an editing process that produces good audio and visuals that are unique from the competition so that they have an advantage and sell effectively in the market how to proceed when audiovisual products or songs are published or marketed in the form of digital files that can frequently be played and downloaded as a reference for sharing to groups on social media platforms when a digital file music product is uploaded to youtube it can gain thousands of subscribers and be monetized to generate rupiah or when the digital music files go to paid digital music sales services such as sky music and joox they can generate royalties the ecosystem in the distribution subarea necessarily requires collaboration between music managers and paid digital music sales services dian primas management believes that it is critical to distribute digital music files targeting various market segments download subscriptions from paid applications typically come from a small circle of uppermiddleclass educated and professional people where they have their own culture of consuming digital music by preventing free downloads because it is considered risky tarling music managers learn a lot about song products with different market segments due to the way paid music service providers work creativity and innovation in digitalization practices are used to produce products that are suited to market tastes such as making digital music files that differ from the tastes of the lower middle class who are accustomed to free downloads via social media channels or youtube tarling music manager agents can now easily distribute the music they produce through various online media either through social media streaming services or web pro files the emergence of social networking sites such as my space in the early 2000s was a sign that the digital era had penetrated the music ecosystem my space provides space for everyone to create a page containing their own profile including their own music continuing in 2006 reverbnation specifically provides a meeting place for musicians who want to release their work with listeners through reverbnation musicians who have just released their work will have the opportunity to be heard more widely and have the opportunity to play at festivals without going through label intermediaries the era of digitalization is recognized by the tarling manager as providing many opportunities to do promotions for free without having to pay a lot of money what is often an effective option is to promote through social media platform channels to get many fans such as fans from indonesian migrant workers abroad they sometimes become big fans and often order gigs when they return home to hold family celebrations such as weddings circumcisions and other thanksgiving events the fanaticism of tarling music fans among indonesian migrant workers such as hong kong taiwan korea and abu dhabi is felt to continue to take root they actually have an influence on the development of tarling in their home regions they make the youtube live concert a means of communication with fellow indonesian migrant workers and their families back home not a few of the fanatical fans because of their dependence on the diva tarling are willing to dare to pay an advance to the tarling group to order a gig when they return home and hold a celebration youtube is recognized as being able to capture the market share of overseas fans and rabid fans another part of the ecosystem in the distribution subarena is the presence of content creators through youtube new youtubers who are indeed hunting for content from tarling music have sprung up they are tempted by the business opportunity to become a content producer to get the benefits of addsense they came home from being tki in korea and then returned to their hometown to make a video shooting production business for the tarling music group the presence of many video streaming services is considered a partner who can take advantage of each other and benefit each other however video streaming service providers are different from tarling music groups they do not have singers or music groups although their way of working can be part of the work of a music group especially when a music group requires video streaming services for live purposes during concerts on stage exploration of the tarling music ecosystem can be seen from the type of music studio and stage concert arenas music consumption habits and material considerations used or involved in production distribution and consumption including the performance of agents in the digitalization arena mark pedeltys notes emphasize the music ecosystem as well as talk about ethics in preserving the musical environment so the meaning of music depends partly on context and material effects not only on sexuality identity and power therefore ecomusicology becomes truly ecological how music is produced using digital devices while still paying attention to aspects of aesthetic and ethical values simon frith concludes through genres experiencing music and musical relationships in a way that unites aesthetics and ethics tarling music ecosystem in terms of production distribution and consumption continues to change however this does not mean that other aspects of the ecosystem such as the social and environmental environment where tarling music was born cannot be ignored characteristics of the northern coastal community cirebonindramayu who tend to want to show the uniqueness of the region by including cultural values in tarling performances from two regions namely cirebon and indramayu it reflects their identity identity also shows the communitys ideology regarding cultural values how they enjoy performances through the form or formation of the tarling itself which is structured and integral parts for example seen from the lyrics of the song the aesthetic value of tarling which reflects the locality with culinary themes family life and the love story of men and women working abroad these characteristics reflect the value of locality which affects the taste in consuming music tarling is not only enjoyed by the people of cirebon and indramyu the sundanese or javanese people outside cirebonindramayu who live around the pantura such as kuningan majalengka cirebon indramayu and brebes actually prefer pantura tarling songs to sundanese pop songs the reason is because the tarling dangdut pantura song has a fast rhythm and is more vibrant when compared to sundanese pop songs which mostly choose medium rhythms and slow tempos tarling ecosystem in the consumption subarena the arena of digitalization affects how audiences enjoy tarling music the consumption subarena ecosystem makes fans no longer have to be present in front of singers and go up on stage to dance they can now watch concerts of groups and singers tarling virtually through social media platforms in addition to release their longing for the singer who became their idol clients and fanatical fans no longer meet facetoface after the concert another new habit in the consumption subarea is the interaction of musicians with the audience which cannot be done directly because virtual concerts are held at home or in a mini studio tarling musicians must get used to adapting to replace the audience in front of them with cameras and digital devices the adaptation of virtual concerts is accompanied by technological developments to determine the most appropriate form of virtual performance interaction with each artist with the same concept the show can only be performed by singers and a limited number of music crew and audiovisual editors but the show can be watched by the whole world at one time through live streaming they can interact directly online by giving likes comments and share links and can even easily greet the tarling singer by recording audiovisual messages that can be uploaded through the comments column or sent in the private message column for the audience fanatics who are not satisfied with attending virtual concerts they can interact directly with their idol tarling singers through the audience community group made by themselves tarling music audiences can adapt to new habits namely enjoying live streaming tarling music and changing their nyawer habit by sending their donations through the account number of their idol singer or tarling group the ecosystem in the consumption subarena presents virtual concerts as an alternative option the audience is free to choose the form of creativity from music that is increasingly developing through virtual concerts tarling musicians can also adapt to perform hybrid concerts combined offline and online through the theme of gathering with fanatical fans on a limited basis hybrid concerts are an alternative to minimize the production budget outside of the presence of sponsors admittedly the audience will feel different when attending a live concert or festival compared to a virtual concert because it is done using digital devices the audiences appreciation is also shown through social media platform channels that are used as live streaming media including saweran which is usually performed on stage now of course is very different saweran can be transferred through the official account number in diana sastras name or by scanning the ovo barcode listed throughout his performance after the virtual concert is over then the role of a manager is assisted by a digital marketing person who repackages the raw material for tarling music in the form of digital music files to be redistributed and transformed in a chain through all social media platform channels both official and personal accounts of singers to then be accessible to the audience more broadly digital streaming platforms are rapidly changing the way individuals consume digital content this stream provides a new way for content producers to reach consumers and has become an important agent in various music industries tarling music singer agents have their own way in the consumption subecosystem how do musicians take care of their consumers or fans one of which is through digital social media groups such as facebook instagram and youtube apart from accounts created by musician tarling there are also social media accounts created by admins for certain groups of fans with the name fan club the tarling musicians really take care of the fans wishes even when there are invitations to foreign countries such as taiwan hong kong and korea to fill concerts in the context of social charities they also dont hesitate to attend overseas fan clubs are ready to facilitate their idol tarling musicians from making flyers roundtrip transportation ticket facilities airport pickups to hotels where they stay conclusion the study of the tarling music ecosystem reveals that there have been significant changes that have occurred historically which have built the tarling music industrys performance chain the tarling music digitalization arena introduces a new system that refers to the transition from analog device systems to digital methods of operation the role of agents specifically producers managers and singers requires them to be adaptable and subject to the new ecosystem they face in terms of the work environment as well as improving their performance in the production distribution and consumption subareas the tarling music industry undergoes many transformations on a regular basis and as a result agents must adapt to survive in their new ecosystem tarlings music ecosystem bridges the performance of agents in the production subarea by producing digital music files that are performed in the studio room independently or with the assistance of a production house in the distribution subarea the tarling music ecosystem enables agent managers to market digital music file products via digital platforms and various social media accounts meanwhile the tarling music ecosystem in the consumption subarena provides an effective and massive way for singers to build a fan network not only on stage but also through live streaming on social media platforms such as instagram facebook and youtube

tarlingmusic which evolved from classical to modern is deeply connected to the digital era the changing music ecosystem is viewed not only historically but also through the various change phenomena that occur the ecological role of producer agents managers and singers in the digitalization arena where tarlingmusic has historically faced two phases classical analog and modern digital this study used a qualitative method with a case study approach from an ecomusicological perspective as a result this study discovers a sociomusical phenomenon that holistically divides the tarlingmusic ecosystem based on periodization and the roles of agents in the music industry including production distribution and consumption subareas producer agencies managers and singers are navigating a new digitalization ecosystem that is influencing how they

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introduction data are growing exponentially in volume velocity and variety creating unprecedented opportunities to inform and transform society governments businesses researchers and citizen organizations are all exploring innovating and adapting to the new world of data 1 however data also raise critical questions about access value and impact who benefits from data and who is left behind how does data production and use shape the surrounding world to address these questions interdisciplinary studies have emerged to examine the social and economic implications of data they believe that the practices involved in producing accumulating and analyzing data have significant consequences on inequality of opportunity and harm 2 3 4 while a longer history of research on information and digital inequalities is useful the data revolution is also producing new forms of inequality that are not easily captured by traditional concepts of digital inequalities and the digital divide a deeper engagement with critical standpoints in research and practice could help to address these in this article we closely engage with a manifestation of this inequality that can be observed in china where a salient characteristic is the dichotomy between urban and rural areas this gives rise to the emergence of an urbanrural divide wherein the progress of the data revolution in rural sectors lags significantly behind that of urban sectors we argue that there are positive correlations between open access to data and ruralurban income inequality based on open government data in china we propose an open government data and income inequality model and examine the economic effects of data opening from the perspective of the urbanrural income gap our analysis expands the connotation of the urbanrural digital divide to a new generation of datadriven digital divide and provides policy recommendations for accelerating the balanced development of digital villages and cities to narrow the digital divide in the context of the data revolution and data for development this paper addresses the issue of data inequality by focusing on a more specific topic the consequences of open government data on the urbanrural income divide in china this paper makes several marginal contributions to the literature in the fields of economics of data and critical data studies firstly while most relevant studies attempt to fit data inequality into broader ict gaps and digital divides conventional understandings of digital inequalities are not always sufficient to explain and address some causes forms and consequences of emerging inequalities resulting from the data revolution 56 therefore this article examines diverse data inequalities ranging from imbalanced data production and unequal data access and utilization by different social groups to income distribution we attempt to distill the divide into an economic model of data production and income distribution whereby data inequalities between urban and rural sectors are shaped accumulatively secondly the difficulty in measuring data amounts and distinguishing the effect of data from the overall technology effect hinders most current studies from devoting sufficient resources towards deeper engagement with evaluating data inequality in this article we attempt to address this shortage by studying a prototypical setting open government data in china and its consequence on the urbanrural income divide using multiperiod differenceindifferences estimation section 2 provides a comprehensive review of the literature highlighting the concerning impact of technological progress and the economics of data in a digital age building on this in section 3 we develop an economic model to examine the effects of open data access on the urbanrural income divide our model yields a critical prediction that guides our subsequent empirical analysis in section 4 we describe our data sources variables and methodology which employs a differenceindifferences estimation approach we exploit the exogenous variation in the timing of government data openness across cities and years to assess its causal impact on the urbanrural income divide section 5 presents our econometric results and robustness tests through this analysis we contribute to the literature regarding the impact of open data access on the urbanrural income divide which has important implications for policy and economic development related literature while the exact extent of ruralurban income disparity in china is debated due to discrepancies in data sources and methods it is generally acknowledged to be significant 7 with china having one of the highest urbanrural income ratios globally 89 and numerous studies have investigated this divide the urbanrural income gap accounts for a substantial portion of chinas overall income inequality ranging from over 50 percent in most studies to approximately one quarter 9 xie and zhou found that this gap contributes to over 10 percent of total national inequality in china but is negligible in the united states 10 overall the majority of studies indicate that urbanrural income disparity is the primary contributor to chinas income gap 1112 many studies have attempted to identify the fundamental causes of rising income inequality in china the most often suggested tested and examined causes are as follows first early political strategies promoted heavy industries and manufacturing 13 consequently urban expansion was fostered by investments favorable policies and financial aid agriculture lagged and was utilized to build other industries urban capital buildup and subsidies were funded by agricultural surplus state control of agricultural output and procurement food price reduction and hukou system limits on ruralurban movement harmed rural inhabitants incomes second industrial restructuring increases the conflicts between state industry and staple agriculture since the reform of the economy in 1978 chinas primary secondary and tertiary industries have changed from 28 percent 48 percent and 24 percent of gdp in 1978 to 7 percent 41 percent and 52 percent in 2018 respectively the relationship between industrialization and income change has been extensively studied 14 third the influx of rural residents into cities drives urbanization allowing for the flow of people skills capital goods and information which contributes to the urbanrural income gap 15 lis survey data suggest that rural migration boosts rural income by enhancing labor productivity of migrant workers and improving allocation of nonmigrant workers 16 urbanization may also narrow the urbanrural income gap the development of financial sectors may be the fourth reason for income disparity studies show an inverted ushaped relationship between financial development and income distribution as well as a significant widening of the urbanrural income gap due to financial intermediary evolution 17 there is also positive and negative causality between financial development and efficiency and the urbanrural income gap 1819 scholars have also looked at the gap through the lens of human capital guo found that low human capital accumulation in rural areas leads to stagnant income growth while urban areas have more sustainable and balanced growth with high human capital accumulation 20 the effect of chinas opening up reforms on urbanrural income inequality is inconclusive wei and yi found that the reforms narrowed the gap in around 100 cities 21 while hertel and fan argued that wto accession and market reforms reduced inequality 22 in contrast jeanneney and hua found that the exchange rate policy affected inequality 23 and wei and zhao proved that international trade increased the gap through employment and remuneration effects 24 finally the impact of technological progress on the income divide has been extensively studied and discussed by scholars particularly in the era of the new economy acemoglu argues that the technological progress represented by information technology in the third industrial revolution is generally skillbiased which can explain the wage divide between skilled labor and unskilled labor in recent decades 25 regarding the income gap between urban and rural areas zou and liu find that there is a matching gap between the agricultural skills possessed by rural residents and the industrial skills required by the urban industrial sector leading to lower wages in informal employment 26 according to acemoglu and aghion 252728 the skill bias of technological progress polarizes remuneration growth for highskilled and lowskilled labor this is the same factor that exacerbates chinas urbanrural income inequality the kuznets inverted u hypothesis has been extensively applied to analyze the impact of technology on this inequality 29 30 31 the literature suggests that technology can lead to an initial increase in income inequality due to the concentration of technological innovation in urban areas but after a certain threshold further technological progress can lead to a decrease in income inequality due to the diffusion of technology to rural areas conversely ji et al argue that technological progress in china widens the income gap rather than narrowing it contradicting kuznets inverted u hypothesis 32 li et al and luo and hu find a positive correlation between technological progress and the urbanrural income gap with knowledge capitalization being a significant contributor 3334 however as acemoglu notes different technologies have different effects due to their nature and the data concerned in this paper are different from the technological progress in most of the current literature 25 thus the impact of differentiation especially on the urbanrural income gap deserves attention as a critical research problem in economics the interdisciplinary studies examining the social and economic implications of data are rapidly growing and this paper aims to provide a perspective on the inequality that arises from open data our focus has similarities with the literature on information economics the data market and data access in particular the concept of data as an input of economic activity has been studied in the literature on information economics for example refs 3536 view data as a form of labor and highlight that people may not be adequately compensated for the data they provide our analysis of open data access effects centers on a market for data which is related to the market for ideas in 37 however unlike the market for ideas where only one firm can use an idea at a time our market for data enables multiple firms to use nonrival data simultaneously it is closest to the literature of ali et al 38 which examines the sale of nonrival information in a search and matching decentralized market and demonstrates that nonrivalry can result in inefficiency due to the underutilization of information moreover ichihashi studied competition among data intermediaries 39 while akcigit and liu investigated the social value of sharing information across firms in a growth context 40 although our paper emphasizes the effect of data access on labor most of the existing literature is interested in the effect of data access on industrial organization varian provides a general discussion on the economics of data and machine learning and notes that data are nonrival suggesting that data access may be more important than data ownership 41 farboodi and veldkamp explore the implications of expanding access to data for financial markets 42 while farboodi and veldkamp suggest that access to big data has led to a rise in firm size inequality 43 finally hughescromwick and coronado view government data as a public good and study their value to us businesses 44 concept background and model of data data concept the literature frequently confuses the three terms data information and knowledge due to their overlapping usage hence to establish the conceptual boundaries of data it is important to understand the distinctions among the three in essence the term data refers to raw facts and figures which in turn convey information the assimilation of information generates knowledge at a collective level within a specific social context 45 which can fuel innovation and contribute to improvements in productivity and services moreover knowledge spillovers have emerged as a significant driver of economic growth particularly in situations where resources are scarce 46 in contrast to information which refers to meaningful structured data data are often meaningless and unstructured 47 extracting information from data requires specialized tools and techniques collectively referred to as data analytics 48 economic nature of data scholars often compare data to oil as evidenced by 154950 unlike oil however data are nonrival which implies that they are inexhaustible to generate value data need to be processed interpreted and analyzed by either human beings or automated systems 47 and their usefulness is dependent on application technology and specific scenarios 51 from an economic and social perspective data can be classified into various categories such as publicand privatesector data open and closed data personal and nonpersonal data and usergenerated and machinegenerated data of these open and closed data are most closely associated with datadriven economic growth and improved living standards since data are nonrival opening data can maximize their application in downstream production and the spillover effects of knowledge as suggested by frischmann can enhance the economic and social value of data resulting in increased returns to scale 52 open government data the opening of government data in china represents one of the most significant events in data management as it provides private firms access to a vast amount and diverse types of data collected by the government in delivering public services this open government data initiative has the potential to enhance government transparency enable the public to monitor government performance and hold it accountable for wrongdoings and create new opportunities for economic growth and social innovation private enterprises can utilize ogd to develop new products and services such as realtime roadway traffic monitoring and business trend analysis leading to increased income 5354 opening up government data is of particular importance as it can drive knowledgebased economic growth and this has been supported by recent academic literature 5556 furthermore research shows that the commercial utilization of ogd can result in a positive impact on the performance and productivity of firms leading to enhanced competitiveness 5758 an ogd and income inequality model drawing on the idea of the tkc and the data production model proposed by jones and tonetti 59 we develop a model to examine the relationship between open government data and income inequality in the ruralurban divide given chinas unique dual ruralurban structure we assume that the economic system comprises only two sectors rural and urban the rural sector produces n r varieties of consumer goods while the urban sector produces n u varieties aggregate output in each sector y r and y u is symmetrically expressed in the production function therefore we can construct their production functions as follows y r n 0 y σ1 σ ri di σ σ1 n r σ σ1 y ri y u n u τ τ1 y ui 2 variety i is produced by combining an idea of quality a i and labor l i y i a i l i since data can be used to train artificial intelligence algorithms data d can be regarded as used to improve the quality of knowledge a a i d η i where η determines the importance of the data jones and tonetti 59 suggested that η might take a value of 003 to 010 so we require it as a small positive number much smaller than 1 substitute into and then the production function of variety i is y i d η i l i d η i ln where l is the total amount of labor in the industry symmetrically distributed to each variety the consumption of a product generates a corresponding set of data for instance the operation of a selfdriving car produces data for every kilometer traveled which can be utilized to improve the efficiency of future trips furthermore data on traffic and driving patterns collected and managed by the government can be valuable to selfdriving companies it is assumed that there exists a constant proportional relationship between open government data for rural and urban sectors denoted as x rg and x ug respectively and overall ogd which is represented by x g specifically rural ogd is x rg θx g and urban ogd is x ug x g therefore the data generated in rural and urban sectors can be expressed as follows d ri α θx g n r y ri 1α d ui β x g n u y ui 1β 7 where y ri and y ui denote the amount of data generated by a single firm i in the rural and urban sector respectively x i is the proportion of data available to firm i the quantities n r y ri and n u y ui are the amounts of data generated by other varieties in the two sectors because variety i is infinitesimal for the firms that are symmetric therefore θx g n r y ri and x g n u y ui are the amounts of data that can be used simultaneously by any firm in rural and urban sectors depending on the nonrival nature of data substitute and into the and aggregate output y r n 1ηησ σ1 r x α i θ 1α x 1α g η l r 1 1η 8 y u n 1ηητ τ1 u x i β 1β x g 1β η l u 1 1η 9 with a multiplier 1 1η the more people who consume the variety the more data received this increases productivity and consumes more which in turn generates more data therefore 1 1η is considered the key exponent in the production function l r and l u represent respectively labor input of the rural and urban sector α and β are the marginal output elasticity of rural and urban firms respectively assuming that the market is perfectly competitive and the production function has constant returns to scale the income level of rural and urban residents i r and i u is therefore equal to the marginal income of their labor which can be calculated as i r ∂y r ∂l r 1 1 η n r 1ηησ x i α θ 1α x g 1α η 1η l r η 1η i u ∂y u ∂l u 1 1 η n 1ηητ u x β i 1β x 1β g η 1η l η 1η u equations and show that the marginal income of the labor is proportional to the size of the economy in each sector raised to some power the exponent η 1η captures the degree of increasing returns to scale in the economy that reflects the increasing returns associated with the nonrivalry among data it increases in η the importance of data to the economy this confirms the idea that a larger economy is richer because it produces more data which then feed back and make all firms more productive thus the ruralurban income gap can be measured by gap i r i u n 1ηησ r x α i θ 1α x g 1α η 1η l η 1η r n 1ηητ u x β i 1β x 1β g η 1η l η 1η u 12 finally to analyze how the ruralurban income gap has changed in relation to ogd we take the first derivative of gap with respect to ogd which can be expressed as ∂gap ∂x g η 1η n 1ηησ r n 1ηητ u x η 1η i θ η 1η η 1η x η1 1η g l η 1η r l η 1η u n 1ηητ u x i β 1β x 1β g η 1η l η 1η u 2 13 where the denominator is greater than zero and the numerator can be positive or negative depending on the sign of βα since η 1η 0 from kuznets view 60 the marginal production elasticity of urban capital is greater than that of rural capital during the early stages of economic development when β α stage since production in the digital economy is datadriven data are endogenous and the stage of economic development depends on them so that ∂gap ∂x g 0 and ogd worsens the gap as the economy develops when β α the rural capital marginal output elasticity equals the marginal output elasticity of urban capital at which point the gap peaks beyond this point then β α ∂gap ∂x g 0 economic development and data drive benefit the rural sector more than the urban sector and finally ogd decreases based on the analysis of the theoretical model above we can confirm that the data similarly to other technological advances have an inverted ushaped effect on income inequality meaning that the gap increases and then decreases as ogd grows this relationship between ogd and income inequality can be explained through the transition process as individuals move from the rural sector to the advanced urban sector ogd would at first improve the income of those moving to the latter but exacerbate income inequality for those who remain in the less developed rural sector the disparity in the amount of data opened by the government between urban and rural areas in figure 1 has provided us some clues however as the transition process concludes ogd can narrow the income gap by increasing the data utilization capacity and data amount in the rural sector this improvement in capacity allows rural communities to benefit from ogd thereby reducing income inequality as china is currently in the process of achieving balanced and sustainable development between its urban and rural sectors and is at the beginning of a datadriven economy we believe that the relationship between ogd and urbanrural income inequality is experiencing its initial stage therefore we propose the following proposition between 2010 and 2019 there was a positive correlation between the opening of government data and the widening of the urbanrural income divide data and methodology to evaluate the impact of ogd on income disparity between urban and rural sectors we collected data on the timing of government data availability as well as information on the distribution of income in both urban and rural regions and other pertinent regionallevel characteristics this section provides an overview of the data that we have gathered as well as a description of the econometric methods that we employed ogd context in china in the 1990s before the liberalization of the planned economy in china government and individual information were not disclosed to the public all information was centralized for government use only and individuals were not active agents in the planned economy since liberalization there has been a transformation in the relationship between individuals and the government which has increased the power of individuals and made the government more responsive to their needs as technology has developed and the governments capability of utilizing it has grown china has gradually collected and limited the disclosed information of government and individuals to ensure the right to be informed and information equivalence in a market economy 61 shanghai was the first city to launch the shanghai municipal government data service network in june 2012 and other cities such as beijing foshan and wuhan have also launched government open data platforms in subsequent years the chinese state council issued the action plan to promote big data development in august 2015 stating that data has become a fundamental strategic resource of the country and china will gradually promote the opening of government data resources to society by the first half of 2020 130 government data opening platforms had been launched compared to 18 in 2017 56 in 2018 and 102 in 2019 62 table a1 provides the year in which each city opened its government data the chinese governments 2015 action program for promoting the development of big data mandated the opening of various datasets primarily in the fields of trade and business social livelihood organizations and medical and health care as depicted in figure a1 54 in contrast agricultural and rural areas and credit services have the fewest open datasets this disparity in datasets between urban and rural areas provides important context for our subsequent research the implementation of the chinese governments open data policy has progressed through three stages starting with a slow period of development followed by a period of indepth development with little noticeable change and finally a period of continuous improvement leading to an ogd boom beginning in 2014 63 by the second half of 2021 many cities had datasets exceeding 100 million with dongguan reaching nearly 400 million and a single average dataset volume exceeding 880000 these highcapacity datasets are rich in content related to commerce society market regulation law enforcement and other aspects 64 utilizing highcapacity datasets can provide more value and better reflect the level of openness of a dataset urbanrural income divide data the income information for rural and urban areas was obtained from various sources including the china city statistical yearbook china rural statistical yearbook and local statistical yearbooks of cities and provinces in china these annual surveys provide extensive data on incomes and other household characteristics across china making them ideal for capturing substantial variation and analyzing trends over time while they are nationally representative samplings of the population they do not track individuals over time they provide information on the disposable income of urban and rural residents as well as a wide array of demographic characteristics in the year prior to the surveys to measure the urbanrural income divide we used the theil index for each city and year while the ratio of per capita disposable income of urban and rural residents is a commonly used indicator it cannot fully reflect the impact of changes in the proportion of the urban and rural population the gini coefficient is a more rigorous measure but it requires decomposition among people of different classes and is sensitive to income changes in the upper class the theil index on the other hand is decomposable to study differences in urban versus rural populations and captures changes at both ends of the income spectrum 65 66 67 it represents our studys income divide between urban and rural residents a larger result indicates a more significant urbanrural income divide theil it 2 i1 y it y t ×ln   y it y t x it x t   where i 1 represents the urban and i 2 represents the rural y it stands for urban or rural disposable income in the year t y t stands for total disposable income in the year t x it represents the urban or rural population figures in the year t and x t represents the total population in the year t cities in china are administratively divided into townshiplevel units which are further subdivided into villagelevel units for rural areas and districtlevel units for urban areas however these units are not independent of each other and both rural and urban areas are integral parts of cities given this many studies examining the urbanrural divide in china have used citylevel data to better understand this divide our study focuses on households in villages and urban neighborhoods under the administration of 326 cities from 2010 to 2019 as most ogd are available at the city level our sample includes 2121 city year observations in table a2 we present descriptive statistics on the theil index of the urbanrural income divide which is measured at the city year level in addition to reporting the mean minimum and maximum values of the theil index we also present the standard deviations of the theil index across cities within cities and within city years the crosscity standard deviation of theil is the standard deviation of where theil c is the average value of theil index in city c over the sample period the withincity standard deviation of the theil index is the standard deviation of where theil t is the average value of the theil index in the year t the within city year standard deviation of the theil index is the standard deviation of where theil c is the average value of theil index in city c and theil t is the average value of the theil index in year t these standard deviations help in assessing the economic magnitude of the impact of ogd on the urbanrural income divide methodology following the launch of the shanghai municipal government data service network in june 2012 beijing foshan nanhai wuhan and other regions have also launched government open data platforms successively since government data were opened in different years in different cities it provides a natural setting for an event study to use multiperiod differenceindifferences specification to assess the relation between ogd and urbanrural income divide 68 as an extension of the standard did method multiperiod did allows for more than two periods of data it is used to estimate the causal effect of a policy intervention that begins at different times in different cities in our scenario the did method compares the change in outcomes over time between the treatment group and the control group the regression is set up as follows y c t α βd c t γx c t a c b t ε c t c 1 • • • t 2010 • • • 2019 15 in equation y ct represents theil index of the income divide between urban and rural residents in city c in year t a c and b t are the dummy variables representing the city and year fixed effects accurately reflecting the city and year characteristics x ct is a series of citylevel control variables that change over time these variables were chosen based on the most extensively examined causes of the income divide as discussed in section 2 we accounted for changes in a citys economy over time by controlling the following factors local government influence changes in industrial structure level of urbanization development of financial sectors openingup effect and level of human capital the variables included in x ct are general public budget expenditure as a proportion of the regional gdp the proportion of employment in secondary and tertiary industry urbanization loans of the national banking system at year end as a proportion of regional gdp number of students enrolled at regular institutions of higher education per 100 persons amount of foreign capital actually utilized as a proportion of the regional gdp ε ct is the error term d ct is the dummy variable in which we are interested if the government of city c opens its data in the year t the value of d ct equals 1 otherwise it is 0 the coefficient β reflects the impact of ogd on the urbanrural income divide if β is positive and significant it indicates that ogd promotes the growth of the theil index that is it widens the urbanrural income divide on the contrary if β is negative and significant the divide is narrowed by ogd the did model enables us to solve the problem of omitted variables to a large extent we include year fixed effect dummy variables to control the influence of shocks and trends that change over time on the urbanrural income divide consisting of the business cycle trends in income distributions between different classes and changes in other policies and regulations meanwhile we include city fixed effect dummy variables to control the influence of unobserved timeinvariant city characteristics on the divide ogd and urbanrural income divide preliminary result our empirical analysis is based on the fact that the timing of ogd was unaffected by the income divide in order to test this premise we conducted a regression on the ogd timing to the urbanrural income thiel index and its changes according to the insignificant results of figures 1 and2 before and on the ogd neither the urbanrural income thiel index changes nor the thiel index itself can explain the timing of the ogd this shows that the timing of ogd does not change with the degree of preexisting urbanrural income inequality which is consistent with the basis of the empirical analysis in our study figure 1 shows a scatter plot of the average theil index of urbanrural income divide prior to ogd and the year of ogd figure 2 shows a scatter plot of the average change in theil index of urbanrural income divide prior to ogd and the year of ogd according to the regression results the coefficient is statistically insignificant and no obvious trend can be found in figures 1 and2 main result the results in table 1 show that the openness of government data to a certain extent aggravates the urbanrural income divide we use two regression models to evaluate the impact of government data opening on urbanrural income inequality in these the coefficient of government data openness is positive and significant the second regression results show that even after controlling for several timevarying city characteristics ogd is still positively correlated with widening the urbanrural income divide the regression results showed that opening government data in a city would lead to a 084 percent increase in the urbanrural income thiel index without control variables and a 058 percent increase with control variables to measure its economic effect we compared the coefficient of ogd with the 13 percent standard deviation of the theil index after accounting for the city and time fixed effects the standardized coefficient is 646 percent without control variables and 44 percent with control variables suggesting that ogd can explain more than 40 percent of ruralurban income inequality after controlling for changes in the urbanrural income divide caused by city and time effects the city and year fixed effects explain much more of the total variation in the urbanrural income divide than ogd to assess potential collinearity effects and ensure the suitability of our model we employed variance inflation factors for each predictor the aim was to investigate whether the high r2 values were influenced by collinearity our findings revealed that all vif values were below 5 indicating no significant correlation among the predictors these results provide evidence that open government data does indeed influence the income disparity between urban and rural areas to assess the possible association of other timevarying city characteristics with the timing of ogd and changes in the urbanrural income divide that may be present if the main analysis is flawed but should not be present otherwise it is necessary to test the exclusivity of the effect of ogd on the urbanrural income divide we designed a placebo test by advancing the ogd time for 3 years the result was insignificant indicating that the fakepolicy dummy variable cannot explain the change in urbanrural income divide in the fake scenario and the change in the explained variable is unlikely to be affected by other policies or random factors which passes the test bootstrap test since the ogd began from 2012 in china the number of available samples has been limited we tried to use bootstrap and sur standard error estimators to test the results by creating bootstrap samples from the original dataset by sampling with replacement we randomly extracted the observation results from the data and calculated the impact of government data opening on the urbanrural income divide with the city and time fixed effects we took 500 such samples and estimated the impact of government data openness on the ruralurban income divide by a factor of 500 the standard deviation of the result estimate was bootstrap then the sur standard error was estimated and the nondiagonal elements of the weighted matrix were restricted to be invariant the result was also significant parallel trends test to ensure the results meet the unbiasedness the trend of parallel hypothesis between the treatment and control groups needs to be met if the pretreatment trends of the treatment and control groups are different parallel trends do not hold which questions whether the income divide changes are not caused by the ogd but by other trends therefore it is necessary to verify whether there is a parallel trend in the income divide of treatment cities and control cities before the ogd just like the classical did model multiperiod did can also be decomposed and analyzed for the dynamic economic effects of policies through the event study method but the policy time needs to be treated centrally the regression model is y ct α n ∑ τm β τ d ctτ γx ct a c b t ε ct where ∑ n τm β τ d ctτ is a dummy variable m and n are the periods before and after ogd respectively if city c opens government data in time tτ the dummy variable equals 1 otherwise 0 for example when τ 2 d ctτ represents city c opening government data in time t 2 the regression estimates the effects in the second year after data opening β τ represents the current period of opening government data β m to β 1 represent the 1 m time period before opening government data β 1 to β n represent the 1 n time period after opening government data if the result is significant and equals 0 in the period of β m to β 1 it indicates that there is no significant difference between the treatment and control groups in period 1 m before the opening of government data which asserts that parallel trends hold the result in figure 3 shows that the confidence interval on the left side of 0 includes 0 and the confidence interval on the right side of 0 where the vertical line at each point intersects with the xaxis departs from 0 it indicates no significant difference between the treatment group and the control group before the opening of government data our model satisfies the assumption of parallel trends so the estimated result is unbiased and pure according to the main regression and robustness test results above we can conclude that h1 can be accepted there is a positive relationship between government data opening and the widening of the urbanrural income divide and at the present stage this relationship is becoming stronger and stronger over time impact of ogd and initial conditions to assess whether the impact of ogd on income inequality varies in predictable ways across cities with different initial conditions we built a quantile regression model for the initial urbanrural income theil index with fixed effects the quantiles selected were 02 04 06 and 08 respectively the lower the quantile the greater the initial income divide and vice versa table a3 presents the results showing that ogd has a significant impact on the urbanrural income divide at quantiles 02 04 and 08 all of which are positive the absolute value of the coefficient is the largest at quantile 02 while the absolute value of the coefficient is the largest at quantile 08 among all significant results the results indicate that ogd exerted a larger negative impact on the urbanrural income divide in regions with wider such divides before opening and a smaller negative impact on the divide in the regions where it was initially narrower this provides more empirical evidence of the mechanisms through which ogd influences the divide and also reduces concerns about reverse causality the dynamic impact of ogd on the theil index of income inequality the figure plots the impact of ogd on the theil index of income inequality between urban and rural sectors according to the estimated coefficients and the corresponding standard error information from the above parallel trend test regression we consider a 14year window spanning from 7 years before ogd until 7 years after the dashed vertical lines represent 95 confidence intervals if the vertical lines have an intersection with the xaxis it indicates no significant difference between the treatment group and the control group and vice versa conclusions beyond the enthusiasm for the potential advantages of the data revolution there is growing concern regarding its possible detrimental effects the unequal distribution accessibility and utilization of data exacerbate developmental disparities between individuals and groups this complexity necessitates the advancement of theoretical and empirical frameworks building on the nonrival nature of data we propose a model in which data serve as both an input and an output in the production process products created using data generate new data through consumption and usage which are then fed back into production by constructing a theoretical model of this economic process and examining the role of open government data within it we demonstrate the critical function of open government data and its inverted ushaped impact on labor income inequality our empirical investigation provides evidence that the opening of government data in recent years has positively impacted the widening of the urbanrural income divide in china at the current stage this finding is robust to an array of sensitivity analyses and we find no evidence that reverse causality drives the results moreover the impact of ogd on income distribution varies across cities with distinct initial economic characteristics due to the recent opening of government data in china over the past few years the exact amount of data opened by each city has not been scientifically measured although we were unable to obtain precise data aligned with the continuous variables used in our theoretical models we treated the occurrence of ogd as a binary variable in a did regression for our empirical study despite this limitation the empirical study is still meaningful as it provides initial insights into the potential impact of ogd policy on the urbanrural income divide at the early stages of its implementation in each city these findings align with the research conducted by farboodi 43 and jones and tonetti 59 farboodi suggests that goods or services that heavily rely on data generate higher income compared to others due to the use of data for prediction and the subsequent reduction in uncertainty which enhances firm profitability similarly jones and tonetti argue that data have the potential to generate substantial income with dataintensive goods or services yielding higher income than other goods or services in our study the causal relationship between ogd and the urbanrural income divide can be primarily explained by the disparity in the incorporation of data in the production and consumption of goods between the urban and rural sectors the nonrival nature of data implies that those who generate and utilize data stand to gain significant benefits theoretically a greater quantity of data results in higher returns regarding urbanrural income distribution differences in the marginal production elasticity of capital between urban and rural areas as well as variations in infrastructure professional expertise and digital firms lead to rural areas generating and utilizing less data compared to urban areas during the early stages of economic development this imbalance in economic competitiveness persists when government data become available resulting in rural residents earning lower profits from data furthermore the causal relationship can be also explained by the disparity in the marginal production elasticity of urban and rural capital in china despite the governments efforts to eliminate it the dual urbanrural system still exists currently urban capital exhibits higher marginal production elasticity than rural capital as demonstrated in our ogd and income inequality model in section 34 this preexisting disparity serves as one of the factors contributing to the positive relationship between ogd and the urbanrural income divide observed in our empirical study from a datacentric perspective we propose increasing the availability of data in relatively lowincome areas this could be achieved through the provision of comprehensive broadband infrastructure transportation and logistics in rural communities enabling rural residents to access the digital world in their daily lives and work additionally we recommend encouraging the development of information technology firms focused on the rural market and promoting digital agriculture we believe that providing rural residents with opportunities to derive equal value from the rapid growth of data will gradually reduce the income gap with urban areas and promote equitable development in the digital age data availability statement online space for data storage is being applied for all the data in the research will be shared author contributions conceptualization lt and jp methodology writingoriginal draft preparation lt writingreview and editing jp supervision project administration funding acquisition jp all authors have read and agreed to the published version of the manuscript funding this research was funded by the beijing jiaotong university corporate campus cooperation programresearch on intelligent scheduling system of railway locomotive wheelset repair line and its job creation and substitution effect program no b23sk00200 institutional review board statement not applicable informed consent statement not applicable abbreviations the following abbreviations are used in this manuscript ogd open government data gap ruralurban income gap appendix a in this appendix we provide additional details and data supplemental to the main text

amidst excitement for the data revolutions potential benefits concerns mount over its negative impact as unequal data distribution access and use widen disparities between individuals and groups highlighting the urgent need for advanced theoretical and empirical frameworks this study investigated the impact of open government data ogd on the urbanrural income divide in china our theoretical analysis shows that the nonrival nature of data initially widens the urbanrural income divide before eventually mitigating it resulting in an inverted ushaped relationship using a multiperiod differenceindifferences specification we found that ogd widened the urbanrural income divide between 2010 and 2019 furthermore cities with initially wider urbanrural income divides experienced a greater impact from ogd in expanding this divide these findings provide valuable insights in the role of open data in addressing income inequality and contribute to our understanding of data inequalities in the context of the data revolution

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introduction experts suggest that herd immunity to achieve a 6090 threshold is a way to end the covid19 pandemic a population reaches herd immunity when the average number of people infected by a single sick person falls below one a patient may infect another but that second patient cannot infect a third a vaccine helps individuals immune systems to develop protection from disease a vaccine is not a cure by itself vaccination through a process of administration and distribution reaching to a sufficiently large percentage of a population provides herd immunity that in turn protects the vaccinated as well as the nonvaccinated who may be immunecompromised and cannot get a vaccine because even a weakened version would harm them a plethora of research suggests that vaccination is the most effective method of preventing several infectious diseases such as smallpox polio and tetanus relatedly low vaccination rates have kept the measles outbreak still a concern the countdown to reach herd immunity in the case of covid19 has started with the vaccination several vaccines are being distributed and most of them are highly effective however there is a concern that the vaccines uptake against the transmission and mutation of the virus may not be enough to manage herd immunity concerns arise as to whether the speed at which people are getting vaccinated is fast enough to balance the speed at which the virus is still spreading through circulation and the evolving new strains at which reaching a threshold of herd immunity may not be possible the situation is even more aggravating when more than 15 of americans oppose taking the vaccine to substantially reduce morbidity and mortality from covid19 an efficacious and safe vaccine must be delivered swiftly and broadly to the public as soon as it is available denial or refusal to be vaccinated partial vaccination or have only one family member to be vaccinated is coined as vaccine hesitancy which has emerged as a contradiction to the overwhelming scientific agreement on safety and efficacy of vaccines such hesitancy stems from mostly individuals mistrust lack of confidence complacency not seeing the value access convenience and many other factors but compounded through the ethical debates to make vaccination legal in countries or states vaccine hesitancy is a significant barrier to vaccine uptake and the achievement of herd immunity which is required to protect the most vulnerable populations while vaccine hesitancy has been examined in previous literature on several viruses the proliferation of antivaccination misinformation through social media and various available sources of information in the context of the covid19 pandemic has given this stream of literature new urgency the multifaceted nature of willingness to accept the covid19 vaccine entails different factors for instance vaccine hesitancy maybe because of informational psychologic sociodemographic and cultural factors prior research points greatly toward the socioeconomic determinants of vaccine hesitancy involving qualitative singlecountry work to large scale surveys across dozens of countries similarly studies have also discussed the psychological determinants of vaccine hesitancy some studies have pointed to the information aspects of vaccine hesitancy ie the role of availability of information on vaccination intention during the covid19 pandemic information has been abundant media channels covered the latest developments both traditional and social information channels provided a lot of information prior research suggests these information avenues have a significant role in promoting either vaccination willingness or vaccine hesitancy the covid19 vaccine rollout is ongoing however reports suggest that refusal for vaccination is also high thus it is vital to further investigate the role of information sources on covid19 vaccine rollout this study motivated by this concurrent challenge extends the research around the role of information sources on the intention to vaccinate this study seeks questions on the proposed effect of informational impact in terms of sources knowledge and social media and its various types on vaccination intention and includes other related information factors that have been shown to impact vaccine hesitancy such as psychological impact of health information and perception of governmental efforts this study asks the research question why are some citizens not willing to vaccinate what reasons can be drawn from the earlier research of similar vaccination contexts that can inform policymakers to take some actions to convince citizens for vaccinations significant variations are observed in the willingness to vaccinate by citizens across different countries appropriate tools and mitigation techniques are sparse in the hands of policymakers these challenges along with the beliefs around vaccines influencing health aggravate the third covid19 spread around the delta variant in several countries thus this studys research question assesses the informational factors that impact willingness to vaccinate for covid19 while a myriad of reasons may exist why some citizens are not willing to vaccinate this study is guided by a stream of research relevant to anchoring to the informational aspects of covid19 and citizens perceptions of the vaccine as highlighted next we focus on five major areas derived from extant literature constructs of the health belief model sources of information social media usage knowledge of covid19 treatment and a reliable perception of governments efforts for mitigation we elaborate on these reasons next first the information on the severity of the disease may be undermined there may be a perception that covid19 is a temporary phenomenon and will decline automatically in this context people may believe that vaccine is not a need as such there have been several conspiracy theories floating around on the internet and elsewhere about covid19 these unvalidated rumors put less emphasis on the severity of covid19 as a disease the linkage between severity and action regarding health is wellestablished in the existing healthbeliefmodelrelated prior research thus using this model in this study to explore several belieforiented factors associated with the covid19 vaccination uptake recent studies have examined the healthbelief model to predict vaccine willingness in hong kong and malaysia however empirical examination of the severityvaccine willingness in the covid19 context is sparse yet essential second there may be a genuine fear that vaccination has several unintended consequences apart from side effects subsequently a wait and watch principle may be adopted by citizens such a fearful perception may inhibit their ability to embrace the vaccine however as postulated by the prior health belief model relevant work others adoption of health practices may send actionable cues to a focal person to adopt the practice that being the case in vaccination a significant population may wait for how it affects others and then decide whether to take the vaccine thus exploring whether the willingness to vaccinate is higher or lower by seeing what others are doing in their social media is a salient differentiator to inform vaccine uptake third people worldwide are increasingly consulting the internet social media and their social networks for health information enhancing the role of media in public health promotion thus whether information passed through media can influence vaccine intent remains a concern however there is also substantial potential for harmful misinformation to spread across media platforms fueling vaccine hesitancy media worldwide on covid19 has been instilled with a lot of misinformation a recent analysis of the most viewed coronavirus youtube videos found that over 25 of the top videos contained misleading information reaching millions of viewers worldwide terming the pandemic a pandemic of misinformation repeated visibility of misinformation through media outlets daily causes repeated exposure known to increase fake news beliefs different media outlets have differing characteristics thus the interpretations of covid19 vaccination information may also differ therefore it is essential to understand better different media sources influence on vaccine willingness fourth the question as to whether individuals with higher knowledge of covid19 are more willing to vaccinate remains unexplored the gap in knowledge especially with the mass amount of misinformation in media worldwide may contribute to the increased risk of infection positive attitude and behavioral changes are driven by knowledge and perceptions toward preventive practices examining whether and what type of knowledge enacts covid19 vaccination is essential to ending this pandemic finally governments worldwide and health organizations have not been able to mitigate and manage the pandemic wellenough research has shown that citizens have lost trust in health organizations because some were politicized during the pandemic throughout the pandemic there has been low trust in governments as manifested through the spread of misinformation defiance of public health guidelines and vaccine hesitancy however to reach herd immunity rebuilding government legitimacy is essential one way of enhancing trust is through transparency and disclosure of accurate information decisive government response to the virus has also shown an increase in trust therefore examining citizens perception of mitigation efforts of the government influences vaccine intent is essential to reach herd immunity to summarize following through with hbm we posit that vaccine intent will be influenced by what others are doing and the information available to guide their behaviors this influence is also displayed more so in the digital age in the medias mass influence knowledge of covid19 treatment and reliable perception of government efforts for mitigation all may influence vaccination behavior while the vaccines benefits are clear citizens need to be affirmed and confirmed to take the vaccine the limitations lie in convincing them wellenough with the right knowledge and possibly utilizing media outlets appropriately this study addresses these issues via a perceptual survey of citizens across varying societies methods recruitment this study started with a discussion in a focus group of ten people the focus group participants opined that assessing the hbm and informational aspects is essential to manage vaccine intent the focus group also suggested that different lifestyles and mindsets will differ in vaccine intent this suggestion motivated this study to explore the research question across different countries with polarized mindsets and different lifestyles a global surveydeploying firm collected the data for this study using various online media outlets and organizations to spread the survey the firm recruited respondents from north america middle east europe and asia between december 2020 to january 2021 the firm sampled respondents using age gender ethnicity and geographic regionbased strata and quota matching process by sampling a proportional number of individuals relative to the specified population participation in the survey was free and voluntarythe respondents filled in electronic informed consent that was shown on the first page of the survey the firm protects the confidentiality of anonymous respondents the data were analyzed and received anonymously there were no minors included in the study data was collected using a survey instrument the questions asked participants about their opinion on the covid19 vaccination the survey items included the willingness to vaccinate questions knowledge of covid19 questions informationseeking questions social media usage government perception along with health belief model constructs and several existing validated scales from prior studies the survey instrument was pilot tested using a sample of 18 respondents leading to minor refinements to a few items a total of 385 participants took the survey because of missing responses to the items 13 observations were excluded resulting in a sample size of 372 responses were coded validated and analyzed using stata version 16 sample demographics table 1 describes the variables used in this study we present the coding scheme of the variables from the survey in appendix table 1 table 2 shows the descriptive statistics and pairwise correlations amongst the key variables used in this study appendix table 2 shows the demographic descriptive statistics and as displayed 224 out of 378 of the sample were female in terms of age group the 1827 age group make 331 of the sample the 2837 age group make 384 of the sample the 3847 age group make 169 of the sample the 4857 age group make 56 of the sample and the 58 and over age group make 61 of the sample as for household income level 81 out of 378 of the sample make 30000 annually 54 out of 378 make 3000050000 57 out of 378 make 5000080000 47 the extent to which an individual uses health information sources to attain covid19 information from traditional media eg tv and newspaper isspecial health the extent to which an individual uses health information sources to attain covid19 information from health specialists eg doctors and health websites issocial media the extent to which an individual uses health information sources to attain covid19 information from social media smshortvideo the extent to which an individual uses short video social media platforms to attain covid19 information smcommunity the extent to which an individual uses communitybased social media platforms to attain covid19 information sminformation the extent to which an individual uses informational social media platforms to attain covid19 information smentertainment the extent to which an individual uses entertainment social media platforms to attain covid19 information govstrategy perceived effectiveness of government mitigation strategy against covid19 govperformance perceived effectiveness of government performance against covid19 policy knowsymptoms the extent to which one is aware or knowledgeable about covid19 symptoms knowtreatment the extent to which one is aware or knowledgeable about covid19 and relevant situations five sets of independent variables were of interest in this study first the hbm constructs second the sources of covid19 information third the usage of social media fourth the knowledge of covid19 and fifth the perception of the governmental efforts hbm constructs compose of action cues severity efficacy benefits and barriers to vaccinate for covid19 these variables were operationalized using previous scales and multiitems for reflective constructs were tested for interitem correlation and cronbachs alpha the constructs were standardized and a single variable was generated using a new scale further details are provided in appendix table 3 action cues is defined as triggers for receiving covid19 vaccination that include if others in the community take it if the leader of the country takes it if the leader of the community takes it and if the doctors recommend it the items internal consistency was tested using cronbach α and the standardized score was generated for the response variable as table 2 shows the variable response has a mean of 000 and a standard deviation of 064 severity is defined as perceived severity or degree of harm from engaging in unhealthy behavior the extent to which one will experience suffer or die from contracting covid19 the items internal consistency was tested using cronbach α and the standardized score was generated for the response variable the variable has a mean of 000 and a standard deviation of 080 the perceived benefits of the vaccination has a mean of 000 and a standard deviation of 090 the barriers measures the obstacles to receive covid19 vaccination such as concerns about the safety and possible side effects of the covid19 vaccination the items internal consistency was tested using cronbach α and the standardized score was generated for the response variable the barriers have a mean of 000 and a standard deviation of 079 for the health information sources of covid19 and social media platform use for covid19 information variables each categorical response from the multicategory items were transformed into dummy variables factor analyses using principal factor for estimation with no rotation were performed to identify factors latent to the information search constructs we have provided detailed analyses in the appendix tables 4567 the respondents were asked where they obtained health information on covid19 whether from social media tv newspapers or doctors and health care specialists information source was measured using a count of the total number of information sources used to attain covid19 information factor analysis led us to three main types of sources were measures traditional media sources such as tv and newspapers specialized health sources such as doctors and health websites and social media sources both istraditional media and issocial media had a negative mean of 001 whereas isspecial health had a positive mean of 000 with a standard deviation of 044 social media use examines the extent to which an individual was using specific social media platforms to attain covid19 information factor analysis allowed us to categorize social media platforms into four main categories short videobased social media social communities informational social media and lastly social media for entertainment and social purposes the mean for sminformation and smentertainment was 001 with a standard deviation of 100 and 070 respectively on the other hand smshortvideo and smcommunity were 001 with a standard deviation of 100 and 101 respectively the knowledge variable was coded to reflect the respondents overall knowledge of covid19 using two types of knowledge knowsymptoms knowledge about the symptoms of covid19 and knowtreatment knowledge about the treatment of covid19 the mean for knowsymptoms was 485 showing good knowledge of the symptoms of covid19 yet the mean for knowtrmt was 159 showing a lower level of knowledge on the treatment of covid19 lastly governmental efforts were measured using two variables govstrategy which measures the perceived effectiveness of the governmental mitigation strategy thus far in the pandemic and govperformance measures the perceived effectiveness of the governmental performance against covid19 policy while the perceived government mitigation strategy has a mean of 120 the governmental performance perceived effectiveness is 314 with standard deviations of 048 and 117 in addition to these key variables of interest several control variables as mentioned in appendix table 1 are included to account for counterfactual explanations relevant to our models econometric analysis the empirical model specifies the willingness of individuals to vaccinate for covid19 the independent variables we focused on include hbm constructs information source for covid19 information social media usage for covid19 information knowledge of symptoms and knowledge of treatment covid19 governmental efforts a set of control variables to enhance our empirical models robustness include demographic characteristics of the survey participants such as gender age group household income ethnicity and vaccine availability the empirical model is described below intent to vaccinate i β 0 β 1 ×actioncues i β 2 ×severity i β 3 ×barriers i β 4 ×benefits i β 5 ×covid 19 information sources i β 6 × covid 19 social media i β 7 ×covid 19 knowledge i β 8 ×governmental efforts i controls i ε i since the dependent variables are ordinal values we used an ordered probit model to estimate the key variables parameters with robust standard errors last ε are disturbances associated with each observation using ordered probit regression we estimated to what extent our set of crucial variables influence willingness to vaccinate for covid19 results table 3 presents the estimation results for equation the first set of findings are relevant to the hbm model action cues was positively associated with intent on all four models this finding suggests that individuals are more willing to vaccinate when they see other leaders in their community first getting vaccinated citizens intent to vaccinate is positively impacted by the action of other opinion leaders in the community for example figure 2 displays the total willingness to vaccinate if friends or family take it leader of the country takes it leader of the community takes it and doctors recommend it figure 2 shows that doctors seem to have the highest impact as action cues in vaccine intent followed by friends or family members leader of the country and lastly leader of the community next severity was also positively associated with intent on all four models displaying that the higher the perceived severity of contracting the covid19 disease the higher the willingness to vaccinate benefits of the vaccination also positively influenced the willingness to vaccinate indicating the importance of communicating the benefits of vaccination lastly barriers was negatively related to intent this finding displays that individuals are concerned about the safety and side effects of the vaccination impacting their willingness to vaccinate in terms of information source findings the results indicate that both traditional media and social media as information sources negatively influence individuals willingness to vaccinate in terms of exploring the impact of the type of social media platform as compared to other social media platforms that had no significant influences on intent social media platforms for entertainment and social purposes negatively influences willingness to vaccinate this finding highlights the types of social media platforms that possibly allow the virality of misinformation regarding the covid19 vaccination next we find the coefficients for governmental efforts in govstrategy and govperformance as both negative and significant concerning intent the public seem to have an overall negative perception of the effectiveness of government mitigation strategy and performance against covid19 this in turn has negatively impacted their willingness to vaccinate this negative perception might be due to the uncertainty surrounding the covid19 virus governmental efforts were often misaligned with media coverage and a mix of misinformation leading to a lack of trust in governmental efforts these findings display that perceived governmental efforts directly impact willingness to vaccinate this finding reflects upon the pandemics political ramifications that have been introduced and its negative impact on citizens willingness to vaccinate furthermore the findings display that there was no significant impact on the knowledge of symptoms of covid19 however there was a significant positive influence of knowledge on the treatment of covid19 this finding highlights the importance of knowledge that should be communicated to citizens to enhance their willingness to vaccinate lastly some demographic controls merit attention in terms of willingness to vaccinate age groups 3847 and 4857 are more willing to vaccinate than the other age groups asian ethnicity as compared to other races are more willing to vaccinate lastly north american citizens are more willing to vaccinate than citizens of other countries in the sample discussion this study finds that overall the hbm constructs government efforts sources of information social media usage and knowledge of covid19 all influence willingness to vaccinate these are all critical factors needed to reach herd immunity disentangling some of these may provide some actionable points to increase herd immunity the action cue finding inherently highlights the wait and see action cue from others in the community especially from doctors followed by friends and family country leaders and community leaders this finding is in line with psychologists who have discussed that individuals may fear the side effects or longterm effects of the vaccination and prefer to wait and see people lean toward conformity bias a desire to agree with others and trust others judgment therefore if the network holds strong antivaccine views then the surrounding network will all be impacted thus it is essential to target specific heads of the community to allow for faster dissemination of willingness to vaccinate this finding shed light on how herd immunity can be achieved by initiating vaccinations with certain community heads to illustrate even an antivax may be supporting a leader in other contexts who may influence his or her vaccination such initiation will allow vaccinehesitant individuals to ease into higher willingness to vaccinate this finding highlights the importance of mounting a wellplanned vaccination campaign that involves and demonstrates that leaders doctors and celebrities support the vaccination in addition doctors scientists and politicians should also publicly speak in support of the covid19 vaccine science the finding that perceived severity influences willingness to vaccinate is also crucial to herd immunity with the mass amount of misinformation on the pandemic the diseases severity may be undermined and some people may believe that the vaccine is not needed this finding displays that proper clear messages should be communicated on the severity of the covid19 virus and its cause to individuals infected with the disease this in turn will allow for herd immunity to be reached by influencing citizens willingness to vaccinate furthermore the benefits of the vaccination should also be wellcommunicated the finding highlights that the higher the perceived benefits the greater the influence on ones intent to vaccinate this finding is in line with previous studies that display the importance of displaying the vaccination benefits clarifying the vaccination benefits to the public is one way to displace the misinformation health authorities and policymakers need to clarify any misinformation about the vaccination to the public and control misinformation the perceived barriers of vaccination also influence the willingness to vaccinate this finding suggests that different types of information impact users willingness to vaccinate information about the safety and side effects of the vaccine has a strong impact on ones behavior this important finding displays how policymakers need to provide more informative insights and disseminate clear messages on such topics the next set of findings highlights the importance of information sources on willingness to vaccinate this study finds that media both traditional and social media negatively impact ones willingness to vaccinate such finding is significant displaying the negative impact politics and misinformation has had during the pandemic and its impact on citizens trust surprisingly this is consistent across the sample indicating an overall negative media impact social media companies need to police their networks and eliminate false information about the covid19 vaccine trusted scientists and politicians need to speak in support of covid19 vaccine science on all media platforms lawmakers should do more to regulate sources of misinformation just as they have done for other threats to health such as tobacco digging deeper into social media the study finds that specific social media platforms are used more for entertainment purposes than informational purposes hurt the willingness to vaccinate this finding displays the types of platforms with the stronger virality of misinformation therefore even stricter measures should be taken on such platforms in addition this information needs to be wellcommunicated that such sources should not be trusted policymakers and governments should appropriately utilize social media and information channels by spreading clear information on vaccination and its benefits to further the above finding on misinformation and distrust the study displays that negative perception of governmental efforts harm willingness to vaccinate the pandemic was an information crisis uncertainty distrust and fear were further accentuated by the role played by media platforms and in particular social media in distributing misinformation which led citizens to speculate on governmental efforts the pandemic seems to not only rely on but may change the extent to which people trust institutions this finding goes in line with the lack of trust in general and the pandemics political ramifications the public seems to have an overall negative perception of all sorts of media whether from the government or other sources lastly the study highlights the importance of awareness and knowledge to covid19 types of covid19 knowledge and informationtreatment information has more substantial influence than others communicating information on the methods of treatment of covid19 influences the willingness to vaccinate this is a finding that policymakers and influencers can utilize to avail such information to the public to reach herd immunity limitations this study examines factors that influence citizens willingness to vaccinate for covid19 at a point in time however the citizen might go back and forth in the decision process and the knowledge level or source of information or other factors may change over time this is a limitation of this study as the data set used is a crosssectional survey furthermore the questionnaire was on the internet therefore respondents are all users of the internet the study does not examine noninternet users which could have differential impacts thus the generalization of the sample to a uniform national culture characteristic is a limitation of this study future studies could conduct both internet and noninternet surveys and examine the difference in willingness to vaccinate due to various resource limitations during the disease crises and movement restrictions worldwide the study sample is small limiting the generalizability of the findings however we note that even with the small sample the study has significant implications and insights on the current vaccination behavior of people lastly the crosssectional design may raise concerns about the predictive value of the study we note that the results and any mention of influence in the paper should be taken with the associational value conclusions vaccination is a public intervention that will lead to herd immunity the central part of vaccination uptake is public confidence or trust this study points to important predictors of vaccination intent that can help government authorities design and deliver targeted intervention programs to enhance covid19 vaccine uptake predictors of vaccine intent include action cues of other leaders taking the vaccine high perceived benefits of the vaccine high perceived efficacy of the vaccine high perceived severity of contracting the covid19 disease and lower perceived barriers to receiving the vaccine with the plethora of misinformation media seems to have an overall negative impact on vaccine intent and in particular entertainmentbased social media platforms have a more negative influence on vaccine intent than informationalbased social media platforms controlling and clarifying information is very important as knowledge of covid19 treatment positively influences vaccine intent furthermore the misinformation and distress of citizens with the covid19 pandemic is apparent with the negative perceived governmental efforts hurting the vaccine intent which calls for controlling and clarifying information data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements the patientsparticipants provided their written informed consent to participate in this study supplementary material the supplementary material for this article can be found online at 2021715931full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

widespread acceptance of covid19 vaccination is the next major step in fighting the pandemic however significant variations are observed in the willingness to take the vaccination by citizens across different countries arguably differences in vaccination intentions will be influenced by beliefs around vaccines to influence health often perceptions of what others are doing and the information available guide individuals behaviors for vaccination this is more so in the digital age with the influence of the internet and media this study aims to determine the factors that impact willingness to vaccinate for covid19 we examined factors associated with acceptance of vaccine based on 1 constructs of the health belief model hbm 2 sources of information 3 social media usage 4 knowledge of covid19 treatment and 5 perception of governments efforts for mitigation randomly sampled online survey data was collected by a global firm between december 2020 and january 2021 from 372 citizens with a response rate of 966 from multiple regions including north america the middle east europe and asia ordered probit regression suggests that the health belief model constructs hold perceived severity of covid19 p 0001 and action cues of others taking the vaccine positively influences a subjects vaccine intent p 0001 perceived benefits and perceived efficacy of the vaccine positively influences a subjects vaccine intent p 0001 perceived barriers negatively influence vaccine intent p 0001 interestingly as for media usage mainstream media eg tv newspaper p 0006 and social media p 0013 both negatively influence a subjects vaccine intent social media platforms that are more entertainment and socialbased such as whatsapp instagram and youtube have a negative and significant influence on vaccine intent p 0061 compared to other more informationbased social media platforms eg twitter linkedin knowledge of covid19 treatment positively influences vaccine intent alhasan et al social media influence on vaccine uptake p 0023 lastly governmental efforts perceived reliability in mitigation strategy p 0028 and response efforts p 0004 negatively influence vaccine intent the study highlights the waitandsee action cue from others and leaders in the community it also informs the importance of shaping media information for vaccination through informative media and social media outlets to counteract any misinformation

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introduction a man in malaysia was sentenced to two years in prison in september 2018 for killing a pregnant cat at a laundromat the following year in august 2019 a dog was discovered dead with two arrows in its body in january 2020 a kitten was found with its legs and snout removed in 2021 a man was caught on cctv killing a dog with a bow and arrow and the footage went viral in october 2022 a property manager was charged in the magistrates court for flinging a cat to its death from the 15th floor of an apartment in petaling jaya recently in march this year a cat lover in kuala lumpur was found keeping numerous cat skeletons and carcasses in his condo unit and the discovery was made after complaints of a foul smell leading to a police report the enforcement division director of the department of veterinary services zaharinan abd aziz reported that as of september 2021 276 animal cruelty and neglect complaints had been filed but only 39 of them were investigated and eight of those cases were brought to court under the animal welfare act 2015 stuckis states that animal rights can be understood as animals having claims against humans or the state resulting in duties to avoid certain actions or provide certain goods or services this structure of claim rights is suitable for animals as they are passive rights concerning the conduct of others and are enjoyed rather than exercised by the right holder this means animals have rights to refrain humans to do certain acts towards them therefore in order to deter the occurrence of such crimes against animals the causal factor must be understood especially in malaysia there is a problem in the malaysian society because despite having legislations against animal crimes such as the animal welfare act 2015 section 428 of the penal code and the wildlife conservation act 2010 crimes against animals is still occurring this problem has negatively impacted animals animal lovers and malaysias animal protection index world ranking because of heinous crimes being committed all over malaysia against defenceless animals perhaps a study which investigates the causal factors of animal crimes in malaysia could remedy the situation literature review definition and scope of animal crime and animal welfare animal crime encompasses various acts of violence cruelty or neglect directed towards animals such as domesticated animals livestock wildlife and laboratory animals examples of animal crime include animal abuse neglect abandonment animal fighting and poaching such crimes not only cause harm suffering and death to animals but also pose risks to human health safety and overall wellbeing while animal welfare refers to the moral and legal obligations humans bear to guarantee animals are treated with respect compassion and honour it encompasses the physical and mental wellbeing of animals ensuring they receive adequate food water shelter veterinary attention and compassionate treatment additionally animal welfare involves safeguarding animals from harm mistreatment and negligence while advocating for policies and practices that prioritize their welfare according to the world organisation for animal health under chapter 711 of its terrestrial animal health code animal welfare is defined as the physical and mental state of an animal in relation to the conditions in which it lives and dies further stated under the same chapter an animal experiences good welfare if the animal is healthy comfortable well nourished safe is not suffering from unpleasant states such as pain fear and distress and is able to express behaviours that are important for its physical and mental state good animal welfare requires disease prevention and appropriate veterinary care shelter management and nutrition a stimulating and safe environment humane handling and humane slaughter or killing while animal welfare refers to the state of the animal the treatment that an animal receives is covered by other terms such as animal care animal husbandry and humane treatment animal welfare laws aim to minimize rather than completely ban lawful activities such as slaughtering while anticruelty statutes prohibit specific intentional actions that could harm animals like kicking goal 3 of the sustainable development goals one health approach involves a collaborative effort across diverse disciplines to achieve optimal health for humans animals and the environment it acknowledges the interconnectedness of human animal and ecosystem health and welfare by implementing effective animal welfare policies and ensuring their enforcement we can effectively mitigate animal crimes causal factor of animal crime the article by nurse emphasizes a significant factor which is the link between animal crime and other types of criminal activities it suggests that animal abuse can serve as a sign or predictor of various forms of criminal behaviour including domestic violence child abuse and serial homicide a research indicate that animal cruelty exhibits similar causal pathways and risk factors as observed in other forms of aggressive behaviours according to a study individuals arrested for animal cruelty were also found to have a higher probability of prior domestic violence and drugrelated offenses this indicates that animal abuse might be an early warning sign of more severe criminal behaviours and could be linked to underlying issues like a lack of empathy or poor impulse control certain authors propose that social and economic factors play a significant role in animal crime burchfields research discovered that areas with higher poverty and unemployment rates had a greater prevalence of animalrelated incidents this might be attributed to limited access to resources leading individuals to resort to criminal behaviour for survival additionally the availability of resources like veterinary care and animal control services could influence the occurrence of animal crime as mentioned in the article other authors also support this view contending that neighbourhoods characterized by high poverty unemployment and crime rates are prone to experiencing issues with animal cruelty these areas may lack the essential resources and infrastructure to ensure proper animal care and residents might be more inclined to engage in abusive behaviour towards animals due to the burdens of economic and social stressors the article by burchfield emphasizes another crucial aspect which is the impact of cultural norms and attitudes towards animals the research revealed that individuals involved in animalrelated crimes tend to perceive animals as mere property instead of sentient beings with rights this perspective is often reinforced by cultural norms and can be influenced by factors like race gender and socioeconomic status additionally certain authors propose that systemic factors such as the industrialization of animal agriculture can also play a role in animal abuse the largescale production of animals for food and other products can foster a culture of apathy towards animal suffering and may result in inhumane conditions and practices lastly many studies found that ineffective law enforcement contribute to the rise of animal crimes burchfields study also discovered that animal crimes were frequently not reported and law enforcement agencies might face challenges due to inadequate resources and training to efficiently investigate and prosecute these offenses other studies strongly corroborated this claim identifying the enforcement gap in animal laws as a primary causal factor leading to an increase in animal crimes despite the presence of relevant legislations animal crime in malaysia the animal welfare act 2015 in malaysia is designed to combat animal abuse and cruelty it defines the rights and wellbeing of animals and enforces penalties for those who breach animal welfare laws the law covers various animals including domestic livestock and wildlife it mandates animal owners to offer proper care shelter and food while banning practices like animal fighting and mutilation the department of veterinary services oversees enforcement and investigates complaints related to animal welfare nevertheless both the department of veterinary services and members of the justice system have not made full use of the animal welfare act 2015 instead offenders are often charged under the penal code resulting in lesser penalties and diminished deterrence effect consequently leading to recurring animal crimes the authors argue that the current animal protection regime offers insufficient protection to stray animals evident from the rising number of reported cases since the implementation of the animal welfare act 2015 in the unreported case of mohd nizam bin itam v public prosecutor the appellant threatened victims with a firearm and killed a dog with a firearm at their residence however the appellant was charged solely under the firearms act 1971 and the penal code for criminal intimidation neglecting section 30 of the animal welfare act 2015 which forbids shooting certain animals without authorization additionally the appellant had previously killed three young dogs without facing charges or conviction the court recognized that the appellant committed severe offenses under the animal welfare act 2015 and each offense could have led to fines or imprisonment nonetheless the appellant was not charged under the act a research study was carried out to investigate the connection between childhood cruelty to animals and psychological adjustment in malaysia the study included 346 participants from various regions and data was gathered through selfreported questionnaires the survey assessed participants encounters with childhood cruelty to animals psychological wellbeing and other factors like age gender and household income the study findings indicated a strong correlation between childhood cruelty to animals and poorer psychological adjustment in adulthood it is found that individuals who reported engaging in animal cruelty during childhood were more prone to experiencing symptoms of depression anxiety and aggression later in life compared to those who did not engage in such behaviour and additionally guilt and shame were identified as mediators in the relationship between childhood animal cruelty and psychological maladjustment moreover certain authors contend that acknowledging animals as sentient beings is crucial to enhance animal welfare and decrease animal cruelty in malaysia they assert that the current legal framework in malaysia concerning animal welfare is insufficient in safeguarding animals from harm this is in line with the previous study brought forward by burchfield where individuals who engage in animalrelated crimes often view animals as property rather than sentient beings with rights further according to goal 1 of animal protection index 2020 on recognition of animal sentience and prohibition of animal suffering malaysia rank c in formally recognising animal sentience and the world animal protection believe that a formal recognition of animal sentience in the legislation may be able to underpin further animal welfare measures methodology the doctrinal approach methodology employed in this paper examines the causal factors of animal crimes in malaysia the research aims to investigate the causes of animal crimes in malaysia and propose measures to mitigate such crimes doctrinal approach is a suitable method as it enables the researcher to adapt the research to the local context by analyzing literature from other countries and modifying it to suit malaysias unique circumstances discussion and recommendation the study highlighted in the literature review suggested several causal factors of animal crime and a strong association between childhood cruelty to animals and poor psychological adjustment in adulthood emphasizes the significance of addressing animal abuse as a potential early indicator of more severe criminal behaviors and the need to consider underlying factors like lack of empathy or impulse control further social and economic factors are recognized as key contributors to animal crime where areas with higher poverty and unemployment rates are found to have a higher prevalence of animalrelated incidents possibly due to limited resources leading to criminal behavior for survival furthermore cultural norms and attitudes towards animals play a role as some individuals perceive animals merely as property lacking the recognition of animals as sentient beings with rights lastly the ineffective law enforcement is identified as a major contributing factor to the rise of animal crimes as underreporting of cases and the lack of resources and training in law enforcement agencies hinder effective investigation and prosecution resulting in repeated animal crimes therefore we suggest that public awareness campaigns and educational programs should be conducted to promote animal welfare and humane treatment of animals especially in schools as this will foster a culture of empathy and compassion towards animals and discourage animal cruelty several efforts in other countries such as indonesia has even come out with welldesigned and ageappropriate educative media to impart knowledge on awareness the abovementioned efforts have proven to improve the ability of children to understand better on animal exploitation moreover efforts should be made to address poverty and unemployment issues in certain areas to reduce the likelihood of animal crimes arising from desperation and lack of resources a study conducted on malaysian children showed that family or parents in specifically plays a big part in determining a child behavior towards animals and this behavior towards animals can also indicate if the child may have future problems behaving badly or being violent hence a child that grow up in a happy environment would have better behavior towards animals than those deprived of such family settings malaysia should also formally recognize animal sentience in legislation to underscore the importance of considering animals ability to feel and experience suffering as suggested by world animal protection as it would support the cause for animal welfare measures and encourage a shift in societal attitudes towards animals country such as colombia has formally recognized animals as sentient beings in their legislation and as a result all wild feral tamed and domestic animals regardless of the condition in which they are kept receive special protection against suffering and pain and the authorities have the duty to take action within 24 hours of receiving a report on animal cruelty most importantly the department of veterinary services and the justice system should utilize the animal welfare act 2015 more effectively to prosecute offenders this is because a proper implementation of the act would deter potential animal abusers and lead to more stringent penalties recent cases shows that there is actual light at the end of the tunnel when enforcement bodies other than the department of veterinary services such as police has started to properly charge perpetrators under the animal welfare act 2015 instead of the penal code as seen in the march 2023 case where the court has sentenced the accused to two years of imprisonment rm50000 in fine for starving his cats to death conclusion in conclusion the many literature points out that one of the causes of animal crimes in malaysia involves childhood cruelty to animals as a potential predictor of more severe criminal behaviors in adulthood many study also shows that factors such as social and economic issues cultural attitudes and ineffective law enforcement contribute to animal crimes to combat animal crimes in malaysia we recommend actions include enhancing law enforcement recognizing animals sentient nature increasing awareness and education addressing social and economic challenges improving reporting systems and fostering collaborations with animal welfare organizations by implementing these recommendations malaysia can promote animal welfare and reduce animal crimes fostering a compassionate and responsible society towards animals prioritizing animal welfare will not only benefit animals but also nurture a healthier bond between humans and the natural world a more empathetic stance on animal welfare will lead to a future where animals are treated with compassion ensuring their wellbeing and coexistence with humans in harmony conflict of interest the author reported no conflicts of interest for this work and declare that there is no potential conflict of interest with respect to the research authorship or publication of this article

this research paper investigates the numerous factors influencing the occurrence of animal crimes in malaysia through a thorough examination of literature the study aims to uncover the underlying causes behind the prevalent animalrelated offenses in the country the findings reveal that several key factors contribute to this issue including a lack of awareness regarding animal welfare inadequate enforcement of animal protection laws and cultural attitudes that diminish the value of animals to tackle this problem effectively the study proposes a range of potential solutions these include raising public awareness about animal welfare enhancing the enforcement of existing animal protection laws and fostering a cultural shift that recognizes and respects the intrinsic worth of animals one crucial aspect of this study is its revelation that animal crimes are not haphazard acts but rather they are deeply rooted in social and cultural influences by pinpointing these contributing factors and offering practical remedies this research holds significant importance as it can guide policymaking and direct actions to mitigate animal crimes in malaysia effectively contributionoriginality this study would be able to identify the causal factor of animal crimes in malaysia and hence give light to authorities such as the department of veterinary services and the wildlife department to suggest and create policies which would deter the causes from the root

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introduction nowadays occupational migration for economic reason has become a global phenomenon greatly promoting the society production development 1 in china the economic reform leads the eastern coastal urban regions of china become the front line of industry as well as the major destinations for occupational migrants according to the document publicized by government shenzhen the one of the earliest special economic zone of reform and opening hosts more than 3 million manufactory workers in 2018 which accounts 28 of its residents 2 migrant workers migrating temporarily or seasonally to other regions for occupational opportunities are commonly believed as low social ranked because they usually engage in unstable and unskilled works with economic vulnerability 3 the negative sociocultural economic and psychological change which includes separation from family and familiar social surroundings 4 exclusion from social welfare service 5 discrimination of mobile status 6 and poor living conditions 78 expose mws in a great risk of experiencing adverse psychological consequences 9 10 11 whats more the emerging infectious diseases further deteriorate the health inequality as it increases unemployment risk fuels negative emotion and limits medical resources 12 occupational related factor has become one of the most important maladaptive triggers for depression evolution 13 current available findings implied that compared with nonmigrants mws among worldwide have a higher prevalence of depressive symptoms 14 15 16 17 particularly for female mws 141718 mws major depressive disorders would lead to several negative effects such as disability 19 increasing the risks of unsafe sexual behavior 2021 decreasing the healthrelated quality of life 22 and so on and hence cause a reduction of work productivity and economic growth thus methods should be explored for discerning depression earlier the social rank theory endeavors to explain the evolutionary of depression through its fundamental symptomsdefeat and entrapment 2324 performing entrapment as an entry point to predict and prevent depression it proposes that faced with unfavorable situation such as unachievable goals or negative relationship individuals who lack social power and whose attempts to change or challenge are inhibited will involuntarily yield adaptive responses by automatic shutdown strategy to facilitate accepting current situation 25 if the situation is unacceptable unchangeable or inescapable that the adaptive defensive responses can become maladaptive and eventually result in depression 2627 entrapment a key maladaptive defensive response to provoke depression in srt is described as a common scenario under the adverse circumstances when there is strong flight motivation but the flight is blocked among both animals and human beings 9 based on the recent formulation of srt entrapment would activate the involuntary defeat strategy a genetically hardwired psychobiological response deteriorate the initial sense of defeat and produce a chronic or excessive ids response form a depressogenic feedback loop and finally contribute to the development of depression 28 according to this demonstration entrapment can act as an entry point to prevent depression for entrapment assessment the entrapment scale which contains 16 item was first proposed by gilbert and allan in 1998 9 and it was suggested by paul gilbert that the es should be divided into external and internal subclass 29 the es has been translated into chinese by ruijie gong and applied in students 30 transgender sexual women 31 men who have sex with men 32 successfully however the validity and reliability of chinese version of es among mws are still unrevealed what is more although the association depression and entrapment is confirmed among patients 33 transgender women sex workers 31 and men have sex with men 32 studies among mws are still limited the prospective role of entrapment in depression had been proved by griffiths a w who investigated the longitudinal effects among groups recruited from the workplace and community in economical deprived areas 34 in 2011 manuel trachsel tested the german adaption of the es and assessing the relation to depression and certified the entrapment role in explaining variances in the depression 35 since the chinese version of es hasnt been applied in mws yet the relationship between entrapment and depression of this group hasnt been reported in china in this study we have two aims 1 whether the chinese version of es could be applied to measure mws entrapment effectively 2 how is the association between depression and entrapment in mws 2 what is the optimal cutoff value of entrapment to predict depressive symptoms in mws based on the applicable es materials and methods study design and data collection according to a previous study in 2011 shenzhen mws prevalence of clinically relevant depression was 214 36 we assumed the significant level and permissible error to be 005 and 00214 respectively as the design effect for a stratified multistage sampling was equal or smaller than 1 the expected sample size should be 1411 our mws sample was a secondary analysis of a crosssectional study which conducted from october to december 2019 among industrial workers in longhua district of shenzhena district contained more than 1000 industrial enterprises and one million of factory workers in 2018 37 38 39 a stratified multistage sampling approach was used for recruitment considering the ratios for workers number of different types of factories 16 factories which contain a total of 513215 industrial workers were randomly selected including four mechanical processing plants three electronic devices manufacturers three printing and dyeing factories two chemical raw materials plants one smelter one garment factory one food and beverage manufacturer and one other factory given the median number of workers in a typical workshop of factories in longhua was about 40 to 50 a total of 59 workshops were selected employees over 18 years old and being fulltime employed from the randomly selected workshops were invited to visit longhua district center for disease control and prevention at the cdc our trained fieldworkers briefed the study to the eligible 2700 workers from the selected workshops and 2023 workers completed a selfadministered questionnaire then a total of 1805 mws were extracted from the 2023 workers guarantees of anonymity the right to quit at any time and refusal without any consequence were made to safeguard participants rights written informed consent was obtained we gave a cash coupon of ¥20 to participants who completed our survey measures design of the questionnaire two public health researchers an epidemiologist a health psychologist a health communication expert and a factory worker formed a panel to develop our questionnaire and a pilottest had been done among 20 factory workers to assess the clarity and readability of questionnaire according to the comments of these 20 workers the panel revised and finalized the questionnaire these 20 workers were not included in the actual survey psychological variatesentrapment we used the chinese version of es to assess entrapment es is a selfreport scale designed by paul gilbert and steven allan in the 1998 to identify the subjective experiences of entrapment 9 it has been shown to not only have well validity but also the reliability in diverse settings and multicultural populations 303540 and it was first professionally translated into chinese in 2019 by ruijie gong of which the validity and reliability has been proved among medicine students and the cronbachs for this scale in the study was 096 30 a total of 16 items are included in the scale options for each item range from not at all a little bit moderately quite a bit and extremely correspond to scores of 04 the total score ranges from 0 to 64 a higher score indicates a stronger sense of entrapment the cronbachs alpha was 0902 psychological variatesdepressive symptoms we used the validated chineseversion of the 10 item center for epidemiologic studies depression scale to assess the depressive symptoms of participants in the past week options for each item range from rarely or none of the time to all of the time corresponding to scores of 03 item 5 and 8 need to be scored inversely final score is the sum of the 10 graded items with scores 10 or greater considered as depressed mood 14 the cronbachs alpha was 0902 sociodemographic variates basic demographic information covers age gender hometown type marital status numbers of children education income years of work experience and drinking drinking behavior was assessed by the world health organizations alcohol use disorders identification test which consists of 10 questions the first 8 are fivelevel scoring and the last 2 are threelevel scoring selfreport scores ≥20 were regarded as with alcohol consumption problems 41 data analysis samples demographic and behavioral characteristics were described as numbers and proportions by spss v22 the chisquare test and binary logistic regression proceeded in spss v 22 were used to select potential factors that may influence the association between entrapment and depression the reliability coefficients were calculated through spss v22 the exploratory factor analysis consisted of kaisermeyerolkin test and bartletts test of sphericity as well as the confirmatory factor analysis aiming to test the model fit indices and convergent validity were conducted through spss v 22 and amos v 24 the ratio of chisquare and degrees of freedom between 2 and 5 root mean square error of approximation below 008 goodness of fit index and comparative fit index greater than 09 indicate a good model fitness 42 after proving the reliability and constructive validity of the chinese es we ran the binary regression to analyze the relationship between entrapment and depressive symptoms the scores of the chinese es were demonstrated in the form of median finally the receiver operator characteristic was performed by r × 64 362 for illustrating the sensitivity and specificity of es for predicting depression results sociodemographic characteristics sociodemographic characteristics and their relations to depression among 1805 workers are summarized in table 1 the mean age of those workers was 311 years ranging from 232 to 390 years of the participants the majority came from rural areas of china more than half of them were married 398 were unmarried and only 26 were divorced or widowed besides 72 people refused to disclose their marital status the numbers of children were 448 490 and 62 for none 1 or 2 children or more than 2 children respectively as of the date of the survey most of the participants had worked over 6 years among the participants there were around 33 of participants with depressive risk through the analysis of binary logistic regression five sociodemographic variates display a significance in relation to depression in univariate regression compared with unmarried group the married group was less likely to have depressive symptoms 069 95 confidence interval 056084 compared with the participants without children those owned 1 or 2 children had lower risk of depression symptoms mws who had been working over 10 years were less possible to get depression symptoms when compared with those who had worked less than 2 years for the workers with income higher than 4999 yuan per month they had lower risks of depressive symptoms for the low risks of alcohol use disorders group the group with high risk of alcohol use disorders was more vulnerable to suffer depressive symptoms than them in the multivariable regression for demographic and behavioral variables the income was the only factor that significantly associated with depression the multivariate odds ratio 057 95 ci 038087 when compared workers with 4999 yuan per month with 3000 yuan per month constructive validity and realibility considering that it was the first time for the chinese version of es to be applied among mws we verified its validation before calculating its scores to analyze the association between entrapment and depression 1805 mw were randomly divided into two groups 902 for efa and 903 for cfa exploratory factor analysis to conduct the optimal factor structure of the chinese es we firstly conducted a kmo test and a bartletts test to test the feasibility of applying this sample to factor analysis the outcomes of the kmo test which sampling adequacy was 0961 and of the batletts test indicated the data was appropriate for efa then we applied a principalaxis efa on the covariance matrix of the 16 items from the chinese es the principal component extraction statistics showed that there were 2 factors with eigenvalues greater than 1 43 the two eigenvalues were 9783 and 1112 totally accounting for 68091 of the variance in items suggesting that the twodimensional scale was suitable the factor loading was acceptable as except the first item which factor loading was 0542 other items were between 065 and 085 confirmatory factor analysis confirmatory factor analysis was used to compute and compare the model fit of two models illustrated through the ratio of chisquare and degrees of freedom root mean square error of approximation goodnessoffit index and comparative fit index the first model was the twodimensional one according to the outcome of efa the second model was just a onedimensional model the results in supplementary table 1 suggested the model fit indices of both models were acceptable model 1 the most acceptable one in model fit was applied in the further confirmatory factor analysis each parameter was significant as all of the squared multiple correlations were all greater than 035 44 acceptable item reliabilities were existed all composite reliability were bigger than 06 44 revealing the good internal consistency the good convergency validity of each model was proved by average of variance extracted which were greater than 05 44 reliability the cronbachs α and spearmanbrown coefficient for the chinese es were 0956 and 0917 respectively indicating the good internal consistency reliability and splithalf reliability the relationship between entrapment and depression table 3 depicted the psychological health conditions of entrapment among the participating workers the binary logistic regression displayed a significant positive relationship between depression and entrapment both the internal and external entrapment after adjusted by sociodemographic factors which were significant in above binary logistic regression such significant correlation still existed sensitivity and specificity of the es for predicting depressive symptoms the roc was applied for chinese es to predict the existence depressive symptoms it suggested that the chinese es can predict depression diagnosed by cesd10 among workers well 11 was the optimal cutoff value for predicting depression with sensitivity of 639 and specificity of 828 discussion this study confirmed the relationship between entrapment and depressive symptoms narrated by srt according to the result of constructive analysis the twodimensional es is preferable for mws which was also recommended by the original study 9 however item 11 which was used to belonging to the ie in the original study was classified in ee in this study indicating a possible different classification way in mws when applying es considering the studies on the constructure of es were still inconclusive 303545 we applied both the twodimensional constructure constructed by this study and the onedimensional constructure for binary logistic regression we found that entrapment and its subscales are all significantly related to depressive symptoms combining the above result with roc curve among mws the scores of es over 11 may indicate the possibility of the existence of depressive symptoms our study suggested that mws with less family supports and less working experience were more likely to suffer depressive symptoms this is parallel to the prior research on shenzhen mws 36 it is common for mws to experience workfamily conflict 46 the family support such as family belongings has been proved to be effective in decreasing the association between entrapment and ptsd 47 as well as suicide 48 previous study suggested a ushaped mental health status as time of migration passed by 36 while our study found the protective effect of the longest duration of working experiencethe mws with over 10 years working experience were less likely to obtain depressive symptoms there is a possibility that the social support from working environment may compensate the deficiency of family supports 46 thus we emphasize the importance of family support in reducing entrapment and preventing depression considering the familywork conflict increasing support at work may compensate the loss of family support our result exemplified the low socioeconomic status of mws the education levels of more than 90 of participants are lower the high school or technical secondary school level around 70 of participants earns 30004999 yuan per month being lower than the local average level 49 after adding all demographic and behavioral factors into consideration the income became the only significant factor associated with depressive symptom indicating participants with less income had a higher risk of developing depressive symptoms the economic factor role in eliciting depression might be related to the social income inequality as lins study in 2017 revealed that mws with large income inequality were worst in health statues and had worse social integration 11 there are overt limitations in this study firstly selfreport scales own inevitable information bias and we applied the scale based on the participants selfreport to assess the depressive symptoms which was comparatively less accurate than clinical interviews and as we kept the number of participants from each factory to be similar during the sampling it might affect the representative of our sample since the factory size could be different in reality whats more as our participants are chinese workers who are migrant how broadly and confidently the conclusion becomes accepted in other regions or nonmws are still under consideration besides as this was a crosssectional study with selfreport questionnaire we cannot further explore the causal sequence between entrapment and depressive symptoms and analyze whether there is an optimal cutoff point for es to foreseen depression ahead of time instead of the current depressive symptoms in view of the mutual interaction between entrapment and depression as well as the multiple mental disorders associated with entrapment not only the depression 35 more researches are needed for evaluating the effects of es in early detection of depression conclusions the present study first proved the validity and reliability of chinese version es among chinese mws and revealed a positive relationship between entrapment and depression among mws suggesting 11 was the optimal cutoff point for applying the es to predict depressive symptoms among mws it indicated the future applicable value of the es in clinical research and practice and the need of future studies of prospective research on the entrapment role of predicting depression abbreviations additional file 1 competing interests the authors declare that they have no competing interests

background migrant workers are a group susceptible for depression evolution due to occupational maladaptive triggers the social rank theory illustrates the pathology process from defensive adaptation to depression pointing out the early prevention of depression by discovering entrapment this study aims to reveal the relationship between migrant workers entrapment and depressive symptoms methods a total of 1805 migrant workers in shenzhen were recruited by stratified multistage sampling samples demographic behavioral and psychosocial characteristics were described and analyzed to reveal the relationship between entrapment and depressive symptoms the receiver operator characteristic was performed to find the optimal cutoff point of entrapment scale for predicting depressive symptomsin the binary logistic regression of sociodemographic variables migrant workers who were married univariate odds ratio oru 069 95 confidence interval ci 056084 owned 1 or 2 children oru 071 95 ci 058086 had been working over 10 years oru 071 95 ci 054095 earned 4999 yuan per month oru 068 95 ci 047099 multivariate odds ratio orm 057 95 ci 038087 or with low risks of alcohol use disorders oru 051 95 ci 034075 had lower risks of depressive symptoms after adjusted the aforementioned significant sociodemographic variables migrant workers with severer entrapment were more likely to have depressive symptoms adjusted odds ratio ora 113 95 ci 112115 besides the study proved the reliability and validity of the chinese version entrapment scale preferring a twodimensional structure and 11 was the optimal cutoff value of this scale for predicting depressive symptoms among migrant workersthis result indicates the potential value of entrapment according to the social rank theory on facilitating early prevention of migrant works depression and the application value of entrapment scale for effectively measuring mental status among migrant workers

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the advances in digitalization present more opportunities than ever before for people to be connected paradoxically feelings of loneliness and isolation have grown in recent decades and social isolation has been recognized as an important global threat that affects all age groups in the capability approach exclusion and the inability to relate to others have been recognized as impoverishment as well as a source of further loss the situation also challenges the care professions especially social workers who are centrally positioned to help counter loneliness by developing and piloting interventions in finland social media forms a remarkable part of young peoples lives in 2020 84 of 1624 years old used social media every day young men recorded almost 20 more screen time than young women despite embracing technological opportunities when forming and maintaining social contacts young adults report regularly feeling lonely and socially isolated one of the reasons for loneliness is not being in education or employment the number of such youths has remained high for decades in the developed world the situation has led to a growing phenomenon in developed societies called social withdrawal typified by the group feeling confined to their homes and avoiding social contact consequently social workers and other caring professionals face challenges in reaching this section of youths it seems that the existing services do not meet the groups needs and that there is a lack of understanding of which methods might work more efficiently social withdrawal is a welltheorized and researched phenomenon nevertheless there is a lack of research focusing on practices and technologies that could encourage young people who are socially withdrawn to engage with public services the idea of service users working alongside professionals to design create and deliver services does not fit those who are not interested in attending distrust the system or are unreachable through traditional means the shortcomings of the social care system lead to a constant bias against and exclusion of vulnerable groups with more information about socially withdrawn youth social workers and other service providers could start developing new kinds of support services that reflect the needs of different customer groups online communication is a primary means of social interaction among youths in the developed world and the vast majority use social media platforms regularly digital options are thus suitable means to reach young generations however the potential of digital technologies to aid service provision is hindered by a lack of empirical evidence on how vulnerable groups can be reached through digital means this paper fills these gaps by providing findings from a case study on how social media discussion forums can be used to ensure the voices of socially withdrawn youths are heard the primary aim of this article is to address how youths who are socially withdrawn perceive their situation and to suggest what forms of support would help them in response to the lack of understanding of their worldview the study specifically concentrates on the servicesystem level and the societal obstacles young people believe prevent them from participating in society the articles second aim is to explore how digital technologies could assist in bridging the gap between socially withdrawn youths and social workers and other caring professionals we used finnish discussion board posts as our data source to illuminate the potential of social media as a source of otherwise unattainable information the capability approach is used as a framework to understand how the capabilities of socially withdrawn youths enable them to access finnish societys opportunities theoretical framework social withdrawal and hikikomori syndrome social withdrawal is an umbrella term that refers to individuals isolating themselves from familiar andor unfamiliar others voluntarily and permanently the process often starts in childhood but it seems that many young people do not even recognize withdrawing initially and once they have their condition may already be quite severe social withdrawal has been linked to mental health problems internet and gaming addictions suicide and school shootings the phenomenon emerges from both psychological and societal factors bowker et al listed several correlating factors such as parental relationships disposition peer rejection poor selfimage a tendency to internalize problems and being male husu and välimäki in turn identified the following three factors as contributors to social withdrawal excessively high expectations on the part of society and the impossibility of noneducated youths attaining status income and social capital mental health problems and lack of social skills and lifechanging events beyond the individuals control li and wong explain social withdrawal with reference to microlevel social and psychiatric issues such as family dynamics bullying and negative experiences of the education system while also stating that the phenomenon is strongly influenced by sociotechnological factors such as unemployment reduced or suspended social mobility a rigid educational system and the extensive use of the internet and online gaming research shows that social withdrawal is also somewhat culturally specific being particularly associated with individualistic cultures being out of the education and employment spheres correlates with being socially excluded and as a rule those not in education employment or training feel lonelier than those who are feelings of loneliness might be attributable not only to having fewer contacts but also to a lack of money the presence of psychological strain stigma and a sense of shame one extreme representation of social withdrawal is hikikomori syndrome which originated in japan but is now a worldwide phenomenon alongside the growth of industrialization and individualism and the constant use of technology and social media based on a systematic review nonaka et al concluded that the elements characterizing hikikomori syndrome are not working or attending school a person not socializing outside their home and the condition lasting over six months currently however there is no overarching definition of hikikomori syndrome some researchers include among those affected people who maintain few relationships leave their homes infrequently or have withdrawn for a short period there is also some debate over whether hikikomori is merely a symptom or a primary mental disorder it has been suggested that hikikomori syndrome should be added to the diagnostic and statistical manual of mental disorders as a psychiatric disorder the diagnostic criteria would include the following components a person spending most of the day and nearly every day at home clearly and longlastingly avoiding social interaction the situation interfering with the persons life and the syndrome being unexplainable by other mental disorders while social withdrawal certainly causes problems at the individual and societal level it is necessary to acknowledge that the concern over this phenomenon and its labelling has also been suggested to reflect a moral judgment on the part of the dominant socioeconomic section of society withdrawing has also been presented as a lifestyle choice it is important to ask if professionals and researchers are aware of and able to reflect on their own cultural conventions and values and accept fundamentally different worldviews moreover a narrow understanding of this phenomenon may lead to a generalization of youths being targets of various activation practicesmeaning state policies aiming to push unemployed people into employment or education backed by the threat of sanctions to their social benefits in other words there is a risk of narrowmindedness dominating thinking on the issue which does not leave room to acknowledge youths who have decided to live differently such as in a socially withdrawn manner the paradox of social media early depictions of social media promised an innocent arena for sharing information and interacting socially however as social media matured and became ubiquitous its value as an empowering technology came to be questioned the penetration of social media usage combined with the rapid development of artificial intelligence and machine learning techniques uncovered the ambivalence of social media concerns have been raised over issues such as deep social polarization the rapid diffusion of misinformation and disinformation privacy breaches and data surveillance to put it in a somewhat simplified way what was once thought to be a remedy has become the disease there is extensive research on how youths use social media and the findings indicate several purposes and consequences numerous advantages and disadvantages can be identified benefits reported in studies include enhancing social contact independence and communication developing a sense of connection with others fostering of individual identity and expressing identity reducing loneliness increasing quality of friendships gaining informational and educational benefits health advice and peer support actualizing citizenship through political expression on the negative side studies have identified several concerns social media addiction online meanness and cyberbullying misunderstandings unwanted contact and unintentional disclosures a detrimental impact on cognitive and emotional wellbeing increased risk of depression limited selfregulation and susceptibility to pressure from peers fear of missing out polarizing political engagement and inspiring and worsening psychopathologic behaviors the paradox of social media is palpable social media sites allow youths to accomplish many things online that are important to them sites can help maintain connections with friends and family make new friends create and express identities exchange ideas and give and receive emotional and informational support however social media brings new risks such as peertopeer misbehavior inappropriate and insulting content diminishing selfconfidence selfrespect and selfesteem and the threat of data leakage and connected privacy breaches social media lends itself to acts of selfexpression and identity management and engaging with others social media has also acquired a prominent role in social welfare practices an effect heightened owing to the recent pandemic social media can offer a social worker for example a way to reach existing and prospective clients or a method to assess service needs conduct interventions and evaluate service quality it can be a tool to support case assessment and working with communities social media also offers a window into the lives of the youth and in so doing provides social workers with new ways to understand the experiences and perspectives of youth the capability approach to social withdrawal the capability approach has become an important framework for the evaluation and assessment of wellbeing social arrangements and policies amartya sen and martha nussbaum are among the key developers of this framework focusing on the quality of life that individuals are able to achieve according to sen this should be analyzed in terms of peoples capabilities to function meaning their opportunities to undertake activities they want and to be who they wish to be sen calls these valuable achievements functionings which include for example working resting being healthy and being part of a community the crucial point is the freedom and actual opportunities people have to live the life they want and be the person they aspire to be referred to as their capabilities these aspects are strongly affected by economic and social opportunities political and civil rights and enabling conditions such as health education and encouragement another important element is individuals agency the capability approach offers alternatives to traditional wellbeing measures such as income and challenges the dominance of the neoliberal ideology analyzing the roots of capabilities is important as is understanding exactly how individual traits and social structures manifest in a persons situation sen speaks of the multidimensionality of poverty addressing it as a deprivation of certain crucial capabilitiesnot merely physical ones but also more elaborate social achievements such as participation in a community or being able to appear in public without experiencing a sense of shame exclusion may take an active or a passive form the latter arising through societal processes without actual intention sen claims that unemployment is the most important factor and a major cause of social exclusion in europe the effects of unemployment are not confined to having a low income but include several other personal and societylevel losses these include deterioration of skills confidence and sense of control lack of freedom psychological and physical harm disruptions to social relations passivity and lack of motivation and at the societal level underutilization of productive power increasing inequality and weakened social values and social cohesion fostered by cynicism and hostile attitudes to society the main principles of the capability approach align with the core of social work values as the approach focuses on evaluating individual wellbeing and advancing social justice den braber differentiates three main ways to connect the capability approach with social work strategies and programsthe theory of action for professionals a normative framework for legitimatizing strategies and tools and an evaluative instrument for social policies and actions kjellberg and janssons scoping review revealed that the capability approach was used in social work research in several ways as a method for investigating the sense of wellbeing as a tool for social workers to conceptualize understand and support their clients and in addressing structural inequalities and evaluating social practices sen opted not to specify the list of capabilities owing to the list being dependent on context this vagueness has led to capabilities being operationalized in a variety of ways burchardt and vizard defined ten domains of the most important capabilities connected with inequality life physical security legal security health education and learning standard of living productive and valued activities participation and influence social life identity and respect peruzzi distinguished capabilities based on domains of social exclusion including physical health mental wellbeing enjoyment of relationships participation in political life standard of living access to social services and engagement in productive and valued activities today several of those capabilities manifest themselves online especially with young people through virtual learning social media influencing and forming and maintaining relationships however online options may also reduce the readiness to engage in facetoface activity and have created situations in which some people interact with others only through digital means we aimed to explore how youth who are socially withdrawn 1 perceive their situation and especially which kind of servicesystem level and societal obstacles they feel exclude them from society 2 what kind of supports could benefit them and 3 how digital technologies could assist social workers in reaching these youths this topic is important as the poisonous atmosphere of imageboards allure especially young men who feel mistreated and excluded we do not truly understand their reality data the empirical data were gathered from ylilautaorg one of finlands most popular imageboards particularly among young people ylilauta emerged in 2011 and is a finnish representative of an imageboard an online forum focusing on posting images alongside text and discussion it is not owned by media companies but by a private individual who is also the main administrator the forum is moderated by volunteers and according to the ministry of justice the main platform for finnish hate speech ylilauta describes itself as a privacyoriented anonymous discussion board where you are free to discuss almost anythin one of the discussion forums in ylilauta is called hikikomero which consists of young adults who describe themselves as having no or few social relationships the forums name is based on hikikomori syndrome but is also wordplay as in the finnish language hiki means sweat and komero means a closet users refer to their limited sphere of life and breaking out in a cold sweat if forced to go out in public both sympathetic advice and antisocial behavior toward others coexist on this forum and it creates a subculture and a community of its own marked by participants distancing themselves from society and using negative characterizations of other people hateful comments lack of empathy and misogynous views abound which is common in online imageboards such as 4chan and 8chan hikikomero syndrome has been studied from various perspectives including the differences between the information needs of finnish and japanese socially withdrawn people the participants reasons for their withdrawal and the forums relationship with social exclusion and antisocial behavior we chose this forum as our data source because of its popularity although the participants do not expressly represent the hikikomori phenomenon they spend much of their time online and mainly form their social contacts in that space mental health problems seem common and the participants everyday lives are characterized by fear of social situations and loneliness while the forum permits anonymity surveys reveal that its users are mostly male and aged between 20 and 30 the forum does not offer a representative sample of young finnish people as a whole but does offer a lens on the reality of young men who are lonely and withdrawn method the empirical data consist of messages published during 2018 and 2019 on the hikikomero discussion forum a total of 78095 messages these messages were downloaded on march 2020 from a database owned by a company that each day gathers social media messages written in finnish and published on different social media platforms the study builds on research investigating social withdrawal and the capability approach to provide insights into the world of socially isolated youths the data helped unveil which servicesystem level and societal challenges withdrawn youths feel prevent them from taking part in society and living the life they desire we were particularly interested in working life studying employment services and social services choices motivated by employment and education play a significant role in the lives of young people and in finland those unable to access them consume employment and social services provided by the state the provision of those services carries a threat of sanctions to the welfare benefits of those who refuse to take up proffered activities such as training or work experience placement to avoid the moral judgment of the dominant socioeconomic class we concentrated on messages posted by people expressing dissatisfaction with their situation and who were unable to achieve their desired outcomes figure 1 the data analysis process we deployed thematic analysis in line with our research purposes informed by the capability approach and prior research on social withdrawal our thematic analysis followed the five steps outlined by braun and clarke familiarization with the data both authors explored the messages with a tailored digital tool the main author carried out a trial search with the finnish words osallistua and este the results obtained seemed rather limited so the main author investigated the messages on services working life and studying and found they contained information about the participants capabilities and the obstacles to attendance they faced the authors discussed this and decided to include commonly used words related to these themes to ensure data quality the words were lemmatized in that they were sorted in a corpus to group with all their variant and inflected forms generating the initial codes the authors made independent trial codings from a sample of 100 messages of the 7785 posts identified the differences between researchers trial codes were discussed and further work principles were agreed upon the researchers gathered the posts in excel files and sorted the messages under suitable headings both researchers collated the messages under initial codes chosen according to the research question trial codings and previous research on capability sets and social withdrawal many messages could be assigned to several codes and themes the initial codes the researchers agreed on were seeking work studying employment services society requirements of working life relationships inability to pursue ambitions attitudes of professionals mental health practical hindrances and obstacles proposals and suggestions notes 1 the social insurance institution of finland which pays income support sickness benefits pensions and labor market support for those who dont belong to trade unions or have insufficient work experience to qualify for trade union unemployment benefits 2 in finland being in the closet usually refers to people hiding their sexual orientation however the participants in this forum use it to refer to being confined to their homes searching for themes the main author examined all the collated messages combining suitable codes to simplify the data addressing the issue of some initial codes representing only a few messages and searching for themes present in several or all of the codes the authors discussed the findings and agreed upon seven themes among the messages which seemed to play a part in excluding people who are socially withdrawn from social services and society these themes were personal fears and shame negative service experiences neuropsychological and mental health problems problems with interaction and communication bitterness and hostility toward other people and society the importance of paid work and complicatedintertwined problems that had developed over a long period reviewing the themes the main author read the messages once more marking them according to how they contributed to the research question whether they related specifically to the service system or society in general it became clear that some refinement and combining would be necessary as the distinctions between themes were unclear it is worth noting that there is still some overlap defining and naming themes the researchers had a final discussion about the data the analysis process and the themes found seven identified themes were condensed into two overarching themes which relate to the unsuitability of services and the role of society in exclusion the former encompasses the forum participants extreme reluctance to access services the attitude of service professionals the wrong kind of services and bureaucracy the latter relates to loneliness hard values and the demands of working life findings the current study aimed to determine what servicesystemlevel or societal obstacles socially withdrawn youths feel prevent them from participating in society the results of our thematic analysis resonate with earlier research on social withdrawal as well as sens listing of the effects of unemployment and peruzzis dimensions with the focus being on mental wellbeing enjoyment of social relationships access to public services and engagement in productive and valued activities we present our key findings below with examples of the messages on the hikikomero forum to exemplify the final themes the messages were translated from finnish to english by the authors who aimed to be cognizant of the benefit of retaining the spirit of the forum the meaning of the messages was also checked with an english native who also speaks finnish fluently overall the messages were wellwritten but the syntax of the posts was sometimes untypical the use of the forums own argot was common which often included fabricated words and terms used in nonstandard ways using an online forum to harvest data raises ethical considerations as participants have not been able to give consent to the use of their posts however the forum hosted on ylilauta is anonymous and public and includes a disclaimer that the posts may be used as research material some of the participants might not realize that this is the case as the boundaries between private and public tend not to be explicit in online contexts we have respected the participants privacy we do not individualize any writers or provide any information that could identify them the fact that the text extracts were translated from finnish into english means that the data do not exist in the same format on the internet as in this article we avoided bias by approaching the data openly eliciting the obstacles from the messages however it must be admitted that the research team created the initial categories in advance of data gathering and therefore those categories reflect the teams values such as participation in society being a worthwhile goal the negative connotation of social withdrawal could and should be questioned as it can also be seen as a personal choice however our data make it clear that although some expressed contentment the majority of posts revealed dissatisfaction our findings emerged following a thorough familiarization process with our data that involved two researchers reading the posts three times after the selection phase unsuitable services participants reported factors contributing to their sometimes extreme reluctance to access services those factors included experiences of exclusion and rejection from workplaces schools and society in general and also a lack of comprehension on the part of service providers and those service providers sometimes belittling their clients many of those posting had accessed different forms of social and health services and found them unhelpful or unsuitable i know the lowthreshold meeting places and have visited one but the crowd there seems to be of a different age and i do not seem to adapt to that place lack of money or material resources did not come up as a major challenge confirming sens idea about material resources as a means but not an end to achieving wellbeing unemployment in particular cannot be countered simply by providing social security as it is related to so many other negative effects many forum users professed their dissatisfaction with the help available from the service system or stated none was available the feeling that professionals did not understand their problems or questioned and diminished them was common as seen in writer 1s post that is why one should never ask advice from normal people about ones life because the only responses are like the best lines from donald duck even qualified doctors psychologists and nurses offer this verse advice for real despite knowing very well that you cannot fix neurological disabilities by going to a school for a walk or to a rehabilitative workplace to carve wooden dildos the participants also stated that service professionals patronized them and did not appreciate their achievements and skills if they did not fit the predetermined standards for example if a young person had taught themselves coding but did not have recognized qualifications access to the services listed by peruzzi is not enough if the contact person for that service has a negative attitude or insufficient knowledge of the customers situation the forum users commonly expressed how they found applying for and dependence on benefits humiliating employment services an integral part of social work with young adults in finland were a popular topic many participants felt that rehabilitative work activities were the only service offered to them and in the service professionals opinion work was a cure for all illnesses as well as a remedy for exclusion as demonstrated in writer 2s example these services were generally seen as exploitative and not a valued activity as such the evident frustration was remarkably intense many participants referred to the employment services as slavery and voiced very strong opinions about them however some considered them appropriate and valuable i have even been bullied on employment office training schemes where in practice one works without pay in some company for several months …this is a good help for years of poverty and marginalization as one has to go to get bullied for eight hours five days a week for several months or risk sanctions some participants shared their experience of the problems with finnish bureaucracy and wished the system were more flexible many felt managing the triad of the employment office kela and the social office was very stressful the employment service and kela professionals were considered mainly to be unsympathetic bureaucrats whereas social workers appeared more humane writer 3s post relates to the change when responsibility for the payment of income support was transferred from the municipalities to the stateled kela in 2017 here as well when one could deal with the social services there was humanity in addition they truly tried to help us to move on with our life sometimes they paid full support just to encourage a hobby and buy clothes etc so we dont only get stuck within four walls the whole time kela doesnt have any kind of humanity they are just trying to figure out reasons to cut support and delay decisions probably decisions are made like a conveyor belt which adds even more errors and isolates the customer from them the fear of sanctions applied to their unemployment benefit and income support was a pronounced topic and even though the disability pension was seen as a lucrative target it was also claimed that young claimants are forgotten by society and then loneliness becomes even more difficult to handle as demonstrated in writer 4s post i have ruined everything in my life and grandly nobody offers help anymore not healthcare not the social office or any other place they kicked me out of public health care as i got a disability pension a couple of years ago i have nothing absolutely nothing anymore fear and regret stayed as a friend go to school go to work go to those uncomfortable situations catch those opportunities i didnt i didnt dare and in the end nothing was left the exclusive society this theme consisted of complex entrenched entities revolving around how other people and society contribute to the withdrawal phenomenon in finland the withdrawing process often begins in childhood when some children are bullied or ostracized which is visible in writer 5s text i cannot help my autism i would have wanted to be normal but this is the result of exclusion as they push one into the closet i have my own shit in the background already and then as an adult i still have to try to adapt to society somehow i dont anymore ill tell this whole bustle where to get off and live as a rat meaning living on benefits for the rest of my life then the loneliness in the posts was palpable even though some claimed to no longer need the company of other people and felt being sociable was burdensome the sociability aspect raises the question of whether social relationships are a valuable goal for the participantsa prerequisite of functionings under the capability approach and whether withdrawal is more like a lifestyle choice this finding might partially reflect young peoples social connectedness in the digital age however in light of the forum participants bitterness it also appears to be a response to a lifetime of exclusion and bullying which were commonly claimed in addition to active bullying passive forms included being left out staring laughing whispering and teasing from classmates or coworkers to which the participants were unable to retaliate many participants simply did not know how to make friends writer 6 elucidates the participants attitudes to socializing as well as their tendency to internalize their problems as noted in earlier research i have mainly bad experiences from university illusory freedom of choice makes the useless but obligatory studies feel even more impossible another thing i have noticed is socalled lowintensity bullying i do not want to reveal my subject but in this field a remarkable portion of students are unauthentic popinjays for me it started little by little with long stares and laughter hey nn is here style comments started to be audible sometimes well there are reasons due to certain mental health problems well consciously i dont care about any drama shit but a decent amount of anxiety from which is almost impossible to get rid of is left and friends…zero for sure problems with mental health and neuropsychological disorders especially aspergers syndrome and autism were expressed as obstacles to participating in valued activities and seemed to make the participants feel they were undervalued by society as also showcased in the research results of molin et al there were many mentions of shame which sen offers as a good example of socialexclusionshaped capability deprivation the participants feared they would fail or humiliate themselves in many cases this was linked to negative experiences many participants also seemed to lack motivation they had possessed it once but their life experiences had diluted it and a feeling of being stuck in the home stymied their ability to act some lacked interest in anything and had no dreams or ambitions while some appreciated the freedom and stressfree life coping with only a little money they made comments like as i dont have a life anyway and some criticized the current exaltation of materialism the participants found society lacking in many ways many felt hard values such as competitiveness and productivity had assumed too much importance employment in finnish society was considered hugely important almost to the point of being a prerequisite for having dignity a perception that aligns with sens findings on the link between unemployment and social exclusion the participants felt they were blamed for their situation in public discussions and in their relationship spheres much discussion revolved around participation in productive activities and work in particular was considered a valued activity as the capability approach anticipates access to working life was considered challenging for a variety of reasons most of them internalized such as having the wrong demeanor gaps in the curriculum vitae too long spent studying a lack of experience or education and in contrast being overqualified moreover competition for jobs was seen as extremely rigorous because normal people were also unemployed however many reported having work experience albeit portraying it as mainly negative bullying and burnouts were common with participants claiming they were unable to work the full hours expected in modern working life especially if the job was unsatisfactory or if life did not offer anything positive to counter working life adjustments to working life were considered important several forum participants expressed bitterness that merely working is no longer sufficient in current society as there was an expectation that staff would socialize together too even if the job mainly required solitary work the frustration and disappointment relating to employment seemed to lead to resentment and even misanthropy thus confirming sens findings of enhanced cynicism a sense of exclusion and grievances against society among the longterm unemployed wong suggests that withdrawal can also be seen as a response to the precarious nature of work in the twentyfirst century reflecting the agency of young people in the face of structural barriers negative experiences bitterness and the participants personalities create a kind of downward spiral where encounters with other people are interpreted negatively at some point completely blocking the participants attempts to normalize as they put it the attitude to normal people was usually hostile the inability to relate to others was a deprivation in itself and something that indirectly exacerbated other forms of deprivation the forum participants had had plenty of time to ruminate on past injustices and the hikikomero forum offers peer support for that kind of attitude and may even amplify it the situation highlights the paradox of social media as the forum discussions offer peer support and exemplify prosocial behavior while simultaneously giving prominence to hateful comments and to those displaying no empathy the forum may thus work against the participants deepening their feelings of exclusion as the post by writer 7 shows unknown people are just the group of normal people you dont belong to and by whom you have been discriminated against they talk about marginalized but the correct term is discriminated but they dont use this because it would be inculpatory some random employee might not have discriminated against you but might have been discriminating against some other hikky a person who is socially withdrawn or just allowed it to happen by standing back discussion and implications loneliness is a worldwide phenomenon threatening peoples wellbeing especially in the developed world and is recognized among the grand challenges that social work champions the posts to the hikikomero forum provided a unique glimpse into the lives of youths who are socially withdrawn the obstacles they identify as preventing them from participating in society and the outcomes they deem important the forum participants seem to have access to numerous options geared around finlands university education being free at the point of delivery and its guaranteed basic income for all however in practice the forum participants lack the actual capabilities to lead the lives they want and are constrained from attaining the outcomes they value by various intertwined forms of passive exclusion caused by the demands of working life other people and an unaccepting society additional hurdles include mental health and neuropsychology issues a sense of shame and a fear of social situations social work with adults in finland is closely connected to employability and employment services it is therefore important to discuss which employment services cater to the needs of the members of society who are socially withdrawn the current policy is that one size should fit all that policy results in a situation exemplified in one of the posts where clients of the social rehabilitation service were described as including alkies junkies people with mental health problems and those who were otherwise really deeply marginalized…longterm unemployed the jobs assigned to participants were often monotonous and thus not suited to those who are as one participant put it intelligent but retarded that description would for example encompass highly intelligent people whose potential is constrained by their suffering from a neurological disorder such as autism or aspergers syndrome another implication of the current system in finland and other developed countries is that they should enable opportunities for anonymous and faceless interaction as social anxieties and shame hinder traditional facetoface contact menon and millercribbs state that online counseling may suit those unwilling to seek traditional counseling anonymity confers advantages such as an opportunity for intimacy and to manage feelings of being stigmatized one option could be exploring different social media arenas where previously unreachable groups might be found as social media seems to provide spaces where peer support and professional help are sought and received this is true of the hikikomero forum although the probable contagion of the hostile atmosphere can also be considered a negative effect the atmosphere resonates with the compatibility pressures described in the form of groupthink meaning that members do not wish to express ideas perceived to be unpopular overall the strict division between the facetoface and online worlds seems to no longer be relevant to the younger generations virtual opportunities should be regarded as complementing traditional ones as some previously unreachable groups might be accessible with online methods however the feeling of loneliness was clearly evident on the forum and the extensive use of social media has been linked to social withdrawal one example based on information and communication technologies with the potential to tackle loneliness is the moderated online group in which the presence of a professional ensures a positive atmosphere the results show that a moderated group can particularly benefit lonely youths who find attending groups in person challenging some kind of professional facilitator would be needed in such groups for example to counter the participants limited social skills as exemplified in this hikikomori forum entry if your social skills were left in high school it is extremely difficult to start creating new relationships accordingly social workers should not shy away from the professional use of social media but embrace it especially with youths a group for whom it has proved to have several advantages social media should be seen not only as a way to reach people and maintain connections but also as a source of unfiltered information on peoples situations and needs this approach would counteract the lure of tamed and neutral experiences often present in the service user involvement where participants can find themselves constrained by conditions determining how they should work and present their story the posts examined suggest service professionals would benefit from a greater understanding of their clients secluded lifestyle and neuropsychiatric problems and also of the paths that led them to withdraw such understanding is essential for the early identification and assistance of young people who are not yet isolated but at risk of becoming so as withdrawal is a process conclusion this study explored the potential of social media to elicit information on how youths in finland who are socially withdrawn perceive the social services system and why they believe society excludes them in a way they are seen as expertsbyexperience facing difficulties andor care services in the past sharing their experiences of social welfare and healthcare organizations in practice however it has been found that the expertsbyexperience approach is used to justify an existing rationale consequently collaborative individuals intent on seeking consensus are sought for such roles the practice raises an important question of whether we are willing to hear critics of the service system or society in general and ready to rethink the status quo instead of merely finetuning existing services there are a few limitations to this research the sample was collected from one finnish discussion board in addition using the internet as a data source might risk the contributors being unrepresentative of the target group social withdrawal is such a complex phenomenon that it will never be completely understood by analyzing social media messages however hikikomero and similar social media platforms can provide a unique window into the lives of youths who are socially withdrawn anonymity may foster honest discussion about painful and stigmatizing themes however group dynamics often lead to complaints being exaggerated and the possibility of social media bots manipulating conversations and spreading fake news is a real one the qualitative form of research makes it possible to explore the obstacles to the target groups participation and also examine what motivates them to become involved one possible avenue for further research would be to explore exploiting social media to empower the persons who are socially withdrawn on their own terms and to clarify what those terms would be it is also necessary to focus on public service providers willingness to cross the portal opened by social media gathering information about the situations and challenges faced by youths who are socially withdrawn will remain worthless unless it is transformed into new approaches to practice author note address correspondence to hanna kirjavainen turku university of applied sciences finland email

youths who are socially isolated are largely inaccessible to social work professionals nevertheless most are active on social media feeling they have been let down by society many such youths seek comfort in imageboards where the idea of being antisocial is cherished and where even extremism and hate speech is tolerated this study relies on a thematic analysis of 323 imageboard messages to identify the challenges socially withdrawn youths perceive as excluding them from society we use the capability approach as our viewpoint emphasizing the youths actual capabilities to join in as opposed to the opportunities seemingly provided by society our results resonate with the earlier research many members of the group labeled withdrawn youth suffer from neuropsychological and mental health problems fear social situations experience a sense of shame and failure and harbor bitterness toward society they consider issues including unsuitable services the onerous demands imposed by working life and the hard values prevalent in society to restrict their opportunities to participate in that society and undermine their selfrespect fear and negative experiences prevent socially withdrawn people from approaching social workers accordingly we recommend social services keep an open mind on using digital options to reach people beyond the conventional service system

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• stakeholders identified this limited framing in the consultation process but were largely ignored • a policy narrative politically wedded to austerity was used to frame the problem and select the evidence this narrative was made evident by engaging with wider discourses and critically examining problem representation • using methods from political and social science disciplines reveal new insights about health policies background in 2017 the department of health and social care and the department of education for england released the longawaited transforming children and young peoples mental health provision a green paper 2 the green paper was published when theresa may was prime minister and was presented as a followon from the coalition governments future in mind 3 the green paper aimed to address the rising prevalence of mental health problems in children and young people and the inequalities in life chances faced by children who experience mental health problems in 2021 the mental health foundation reported that approximately one in six children are affected by mental health issues in the uk yet 75 of those affected have not received sufficient support and intervention at an early age 4 approximately half of all mental health conditions first occur for individuals by age 14 and mental health problems are known to persist into adulthood 8 inadequate support for the mental health of children and young people is likely an increasingly worsening problem using the green paper and its consultation process as an entry point 9 into the child health system we draw from different actors and evidence bases within a social determinants of health perspective 10 analysing how external stakeholders and experts responded to the policy and how it addresses the growing mental health crisis among children and young people particularly in relation to inequalities we used bacchis 1 whats the problem represented to be approach to critique policies as political interventions by analysing what is produced through particular problem representations and thus how policy pathways are justified and embedded this paper aims to develop understanding of how health inequality is conceptualised in national policy in order to identify effective pathways to reducing inequalities among children and young people in so doing we develop a theoretical understanding of the pathways through which local programmes and interventions are expected to impact on outcomes of interest within the context of the fluid and adaptive nature of health systems the paper aims to aid understanding of the political agendas to which policy might be tied the historical context for particular policies and the evolving public discussion around developing policy areas this paper speaks to the fields of child equity and health social policy social determinants of health perspectives mental health and inequality policy pathways and implementation policy discourses and the power of discourse in progressing ideological decision making mental health and inequalities in england it has long been established that health is socially and politically produced and vulnerable individuals living in marginalised communities 19 the cqc identified statistics that show higher prevalence of mental health problems in england for looked after children care leavers young people in the criminal justice system lesbian gay bisexual and trans gender children and young people and those with physical disabilities or learning disabilities social determinants of health a social determinants of health perspective explores how individual experience of health is intwined with micro and macro social and political contexts which lead to health inequalities 1521 in england the development of a social determinants of health perspective designed to shape policy culminated in the 2010 marmot review 16 which emphasised the significance of the causes of the causes of health outcomes the review focused on early years education work income and communities as areas in which the social gradient in health was particularly evident with persistent and complex causes and relationships cutting across inequalities in a report considering the marmot review 10 years on marmot et al argue health is closely linked to the conditions in which people are born grow live work and age and inequities in power money and resources the social determinants of health bambra et al 22 illustrate the significance of place in understanding the macro and micro political economy and social influences on health marmot et al conclude that systemwide approaches based on crosssector partnerships are a prerequisite for effective action on the social determinants and health inequalities social determinants of health approaches therefore sit comfortably with walby et al s 23 application of critical realism to social systems as interlinked levels emerging from but not reducible to each other thereby not reducing analysis to the micro level of agency or the macro level of structure both take their place in the analysis at the macrolevel however there are concerns about how both policy and research neglect the structural forces that are key causal factors in producing social and economic inequalities and health inequalities see for example 1214151821 24 25 26 27 despite the evidence there remains a lack of engagement with this knowledge within policy networks and contexts 152829 where policy and policy networks do acknowledge the social determinants of health the politics of power that creates and sustains inequalities and determines health disparities go largely unacknowledged 1517 mental health policy context and the social determinants of health the absences within policy of engagement with the social determinants of health worsened over the past decade through a shift in policy discourse towards a focus on behaviour change and individualism 215 29 30 31 possibly most notably in mental health policy discourse since 2010 28 kriznik et al 29 noted a growth in recognition of multiple determinants of health between 1976 and 2010 but this was not translated into actual policy plans interventions or evaluation plans callaghan et al 28 describe a gradual shift in policy over the past two decades towards a medical model understanding of mental health that focuses more on the biological characteristics and individual determinants of mental health callaghan et al 28 also note a shift in mental health policy from strategies to achieve good mental health for all and enabling people to reach their potential to policies which are more focused on mental health as illness aiming to help people get by a focus on the individual and illness in policy obscures power dynamics and limits engagement with social context which works to minimise the social determinants of health 29 the change in government in 2010 to a conservative and liberal democrat coalition and the introduction of an austerity programme have been identified as a significant change in direction 192829 for callaghan et al the shifts in mental health policy before and after this point in time are dramatic reflecting both changes in government ideology and in the socioeconomic context in which policies are produced and embedded for example the nhs reported that between 2010 and 2013 £50million was cut from child and adolescent mental health services budgets 28 the first marmot review 16 showed that the localisation of health spending pre 2010 had already resulted in areas with the highest levels of socioeconomic deprivation receiving lower budget allocations relative to need subsequently further reduction of funding linked to local authority deprivation levels has led to the areas with the highest levels of deprivation being hit hardest by cuts increasing geographical inequalities 19 whilst some areas improved their performance in terms of geographical health inequalities under new labours health inequalities strategy 31 inequalities remained largely persistent 1617 robinson et al 31 and marmot et al 17 have highlighted the negative impact of austerity on health inequalities and callaghan et al 28 cummins 19 and kriznik et al 29 suggest it has also increased the likelihood of mental health problems associated with social disadvantage researchers and stakeholders have highlighted the barriers to mental health support faced by childran and young people which have worsened due to austerity 1617192032 in particular the high threshold for referral to camhs has resulted in gps rejecting the majority of referrals in some places which discourages young people from seeking further support 32 mental health problems that go untreated are likely to extend into adulthood 1617 and therefore the gaps and problems of inequality in mental health service access and provision must be addressed the impact of covid19 pandemic on the mental health of children and on mental health services will likely further exacerbate inequalities going forward 8 a uk parliamentary briefing in july 2020 33 highlighted the increased need for mental health support for children and young people as a result of the stresses caused by the covid19 pandemic the may 2021 report by the cmh stated that over the next 35 years approximately 15 million children and young people in england will need mental health support as a direct result of the covid19 pandemic in march 2021 the uk government released the covid19 mental health and wellbeing recovery action plan 34 which commits a £15 million investment in preventing mental health problems for the most disadvantaged local authorities however the plans are generally limited to 2021 and 2022 and the scope is limited to predominantly health and social services 835 where a wider scope and longerterm plan is needed to respond to the implications of the pandemic and to continue the implementation the green paper in light of said implications 836 in response to the growing prevalence of mental health problems and inequalities among children and young people in the context of changes in policy and service provision in recent years and the impact of the covid19 pandemic we agree that transforming mental health provision for children and young people is imperative our approach to policy analysis aims to highlight mechanisms that are used in the framing of said transformation that showcase the nature and extent of the response in terms of policy pathways to reducing health inequalities methodology the aim of this research was to investigate the narratives embedded within policy documents and discourses and the responses to them in order to consider the ways in which policy narratives themselves lead to particular outcomes in seeking to understand policy responses to health inequalities we consider these to be both complex and to cut across systems to identify gaps in relation to inequalities in the policy and related consultation documents using a social determinants of health perspective b to identify where such gaps were highlighted in stakeholder responses but ignored rutter et al argue for a complex systems model of public health that conceptualises poor health and health inequalities as outcomes of a multitude of interdependent elements within a connected whole it is important to recognise that adopting a complex systems approach requires a pragmatic approach to research and there will be much going on outside the field of vision of an individual study in this respect wistow et al 18 contend that if we accept that health inequalities are complex then we must also accept that our knowledge is often imperfect and uncertain and therefore requires collaboration between different types of knowledge heads 40 three lenses of evidencebased policy is instructive here and includes political knowledge scientific knowledge and practical implementation knowledge head 40 concludes that the three lenses may suggest divergent perspectives on whether and how to increase mutual understanding and shared perspectives here we follow jessops 9 approach of using policy areas and policies as specific entry points to identify and understand divergent perspectives about the role of the state and associated organisations and actors in considering pathways to change in reducing inequalities in child health 41 in other words investigating policies and how different types of evidentiary bases come together in response to these can be used to enter and explore the complex systems the policies themselves are seeking to influence and change our narrative review used bacchis 1 whats the problem represented to be approach to analyse the green paper on transforming children and young peoples mental health 2 first we identified proposed pathways from national policies expected to lead to reductions in inequalities in child health ie the programme theory of the policy and in so doing identify underlying assumptions about how an intervention is meant to work and what impacts it is expected to have this process was informed by pawson et al s firststep in their model of research synthesis which is designed to work with complex social interventions or programmes and which is based on the emerging realist approach to evaluation we then used bacchis 1 wpr approach to dissect taken for granted ideas within government and external discourses to analyse how problems are discursively created within policy documents through problem representations our focus was on narratives about how policies are conceptualised we use the green paper as an entry point into the governments and key stakeholders understanding of health inequalities table 1 provides an overview of the criteria we used to extract data from both the green paper and the policy discourse across a range of interests and stakeholders arising from this in considering discourses about the policy the inherently political and valuebased nature of policy debate and decisionmaking comes into play which leads head to conclude that policy decisions are not deduced primarily from facts and empirical models but from politics judgement and debate the goal here is not necessarily to identify some underlying causal model as much as it is about exploring and learning how various interventions or strategies might play out for a given policy and the larger complex system in which it is situated after 43 data extraction and analysis the inclusion criteria for the policy extractions was national policies published between 2013 and 2019 which explicitly have a focus on children and young peoples mental health which also explicitly aimed to reduce health inequalities in children and young people a coding framework was developed using the questions in table 1 to extract data from policy documents we then extracted responses using online google searches to capture a range of responses that would be publicly available around key dates in the policy making process related to the coding framework developed we completed a search either when we got to the end of the search results or once five pages of nonrelevant searches were met we also looked at official responses to the consultation process once all documents and responses were coded we used thematic analysis to pull out core themes that cut across the policy documents and responses as well as highlighting absences highlighted by the inclusion of responses broader than the policy documents themselves the key policy document selected was independently double data extracted by researchers with different academic backgrounds to allow more diverse discussion of the findings 44 table s1 shows the results of four google searches carried out in response to a the release of transforming children and young peoples mental health provision green paper 2 b the consultation deadline c the release of the governments green paper on mental health failing a generation report 5 and d the release of the government response to consultation release of government response to the failing a generation report 4546 simple descriptions have been excluded from the table as have responses not directly related to the green paper and subsequent documents or responses not included in findings and analysis in this paper in the findings and analysis section we refer to the stakeholder responses by number corresponding to the table findings and analysis our findings and analysis are split into two sections the first explores problem representation and the pathways to anticipated changes in the policy then we explore assumptions and effects of the problem representation programme theory and problem representation transforming children and young peoples mental health provision a green paper states this green paper … sets out our ambition to go further to ensure that children and young people showing early signs of distress are always able to access the right help in the right setting when they need it the programme theory designed to achieve this ambition is developed across three main proposals that seek to improve access to early intervention for children and young people with mildmoderate mental health problems in order to both reduce waiting times and the impact that mental health problems in childhood have on later life the policy emphasises the additional cost of children and young people seeking medical intervention for mental health concerns from specialist nhs services and the longer term societal financial cost implications of children and young people struggling with mental health problems as key motivations for the policy according table 1 data extraction criteria problem representation 1 • what is the problem represented to be o how does the policy represent the problem under investigation o how has this representation come about o the problem can be inferred from the proposed solution to the green paper the longer term costs of mental illhealth in childhood include unemployment and becoming recipients of welfare benefits as adults links between conduct disorders in young people and criminal activity in adulthood higher costs to public services where mental health problems have progressed and increased likelihood of lost working days due to stress depression and anxiety 2 this focus may imply that saving public money is emphasised more strongly than a desire to reduce inequalities the first proposal sought to encourage all schools through training incentives to appoint a designated senior lead for mental health the green paper considers schools to be an ideal site for early intervention and support highlighting that some schools and colleges already have systems in place to successfully address this need 2 the problem in bacchis 1 sense is thus represented to be a lack of support in schools for early intervention leading to greater pressure on nhs specialist services the premise explained was that parents and wider communities look to schools and colleges for help and advice about responding to children and young peoples mental health needs and so designated senior leads also have the potential to be instrumental in supporting children outside of schools 2 the policy pathway implies that greater support in schools will result in less reliance on specialist nhs support the second proposal was to introduce mental health support teams to work with and between schools colleges and the nhs supervised by nhs mental health professionals we anticipate that in the long term the creation of the new mental health support teams will lead to a reduction in referrals to nhs services as earlier intervention prevents problems escalating as a result it is expected that requests for specialist services would reduce resulting in improved provision of specialist services in terms of efficiency and reduced waiting time for those who need it most 2 the third proposal was the introduction of a fourweek waiting time trial for access to specialist nhs child and adolescent mental health services the national average for waiting times at the time that the green paper was published was about 12 weeks but with significant geographic inequalities for example one provider has an average waiting time of 100 weeks between referral and treatment commencement 2 the introduction of mental health support teams and designated senior leads is proposed to alleviate pressure on medical services and therefore reducing inequalities in waiting times 2 the need to reduce pressure on services is presented in the green paper more as the result of inadequate joinedup working rather than a problem related to socioeconomic characteristics of place or lack of service delivery capacity the aim to reduce waiting times by alleviating the number of nhs referrals presents the problem not as one that is based in place specificities or a lack of capacity but rather as a lack of joinedup working and inappropriate referrals assumptions and effects of problem representation here we extend the analysis of the green paper by focusing on what assumptions are made and what potential effects are produced by the problem representation and programme theory outlined in section 1 and by drawing on responses to the green paper a number of factors were identified as negatively impacting the capacity of health systems to respond to children and young peoples mental health problems these include austerity by not acknowledging or engaging with the impact of cuts on services the government ignores a significant contributory factor for the increased pressure on mh services and long waiting times instead the green paper 2 and the governments response to the consultation 45 maintain that the problem is variable quality of provision in different areas a lack of joinedup working and that children and young people are accessing specialist services for mild and moderate mental health problems that may be better addressed in other settings the responses to the green paper questioned whether the capacity of the designated senior leads will be sufficient due to already overstretched teacher workload there is an assumption that the senior lead role and the whole school approach can be successfully implemented and carried out using only training incentives rather than increased longterm funding for dedicated senior lead roles concerns were also raised about the appropriateness of addressing mild to moderate mental health problems in nonclinical settings and whether nonclinical staff can be as effective in prevention and early intervention while a greater school focus on mental health is welcomed the green paper is criticised for not integrating this in a wider and more ambitious strategy that responds to the rising demand for mental health support for children and young people or by addressing workforce shortages and high staff turnover in camhs and youth work moreover stakeholders have questioned the logic that designated senior leads and mental health support teams will result in fewer and more appropriate referrals as the expansion of support in schools is likely to result in greater identification of need for specialist support furthermore there is a risk that without the proper funding and extra staffing the new waiting time standard may result in fewer successful referrals and more limited support despite that claim that one of the burning injustices of our time is young people facing unequal life chances as a result of mental health conditions the consultation highlights that the green paper illustrates a very narrow framing of the links between inequalities and mental health and wellbeing the focus is on mental health problems exacerbating or leading to inequalities with limited recognition of inequalities as a potential causal factor in mental health problems and no discussion of the role of poverty in mental health prevalence further the green paper highlights families as both crucial to understanding the mental health of children and young people and in responding to mental health problems for example the green paper states that good interparental relationships are another protective factor for child mental health particularly for children living in poverty however the implication that appropriate parenting can protect against mental health problems reflects a limited understanding of the social determinants of health which would address the significance of stressors and pressures outside the family that can result in mental health problems across a family the government responded to these criticisms by explicitly recognising that disadvantage can exacerbate mental health problems and referenced investment in the troubled families programme as a response to working with the whole family to overcome their multiple and complex problems however this programme has been heavily criticised for its framing of certain families as troubled thereby individualising and reducing what are much wider societal problems to a selection of problem families 4748 stakeholders broadly agreed that schools are an appropriate setting for early intervention and provision of mental health support to children highlighting that a school setting may work better for some children as a familiar setting without the discomfort or stigma that may be felt in some clinical settings however some children will experience access barriers to nonclinical settings and not all children are able to access support in schools in the same way for example there may be particular barriers for the 48000 number of children who are outside of mainstream education who are more vulnerable to mental health problems 2 highlight that schools in more deprived areas will have higher demands in response to concerns raised about the green papers school focus the governments official consultation response stated we are committed to ensuring that the mental health support teams reach those most in need of the support and are accessible to all including those not in mainstream education and in independent schools however the response provides little detail about how barriers to accessing services for children outside mainstream education will be overcome other than signalling that the trailblazer approach will address this further access concerns were raised for different groups of children perceived to be overlooked in the policy responses highlighted that some children are more vulnerable to mental health problems such as young carers refugee and asylumseeking families disabled lgbtq and lookedafter children some bame communities and international students and that there needs to be greater focus on specific experiences and barriers faced within child and adolescent health systems in terms of race and ethnicity the green paper highlights that white children are more likely to experience a mental health disorder than black children and that both white and black children are much more at risk than indian children 2 however the green paper ignores the complexity of cultural differences and disparities in access to treatment and experiences with mental health services in its recommendations for example children with disabilities and special educational needs may need support for access communication and interaction with services for the policy to be successful the lack of engagement with different access needs and looked after children specifically in the green paper has led to concerns about the extent to which their access requirements and specific circumstances are accounted for the need to engage children and young people more generally in the consultation process was highlighted to ensure that the issues that affect them most are understood and how they experience mental health service provision and need stakeholders recommend early intervention and prevention that is based on proportionate universalism to cater for all children but targeted to need through proactive case finding for example for children living in poverty in order to reduce inequalities overall stakeholder responses were critical of green papers limited engagement with the importance of inequality predominantly highlighting that mental health support should directly address inequalities and should be more varied and accessible a trailblazer approach was chosen for implementation of mental health support teams and trialling the 4week waiting time standard the benefits of this approach stated in the green paper include identifying local differences in need provision and structures which will impact on the implementation of the new proposals sharing learning about implementation from trailblazer sites with other localities and addressing and ironing out concerns identified in the implementation of planned policy changes the use of a trailblazer approach however has been criticised by stakeholders for not being ambitious enough given the severity of need and gaps in mental health service provision for children and young people as it limits any potential benefits of the policy to no more than a quarter of children in 5 years the potential to increase inequalities by providing support in only a select number of trailblazer areas was also criticised in the discourse about the green paper discussion the effects of policy discourse on policy pathways our findings suggest the green paper develops a generally linear relationship between mental health causing inequality which obfuscates the role of inequality as a causal factor in understanding mental illhealth placing greater responsibility on the individual the policy fits an established wider trend of governments lacking investment in promotion of good mental health 35 instead uk government policy since 2010 has been focused on mental health problems and individual responsibility rather than improving mental health for all as the policy focuses on responding to mental illhealth and inadequacies in mental health care provision rather than promoting positive mental health for all children 28 stakeholder responses highlighted that efforts must be made to ensure mental health support is more varied and accessible than is currently the case for the policy to adequately respond to inequality it must acknowledge the importance of access and there must be a recognition of current barriers and a commitment to removing them 50 absences as evidence marmot et al argue that austerity has adversely affected the social determinants that impact on health in the short medium and long term yet the policy does not engage with austerity and budget cuts at all instead it focusses on and thus the problem is represented to be the way services are organised while stakeholder responses considered issues with joined up working alongside the wider structural inequalities contributing to a mental health crisis among children and young people barriers to access lack of capacity for support within and outside of the nhs and cuts to services that previously provided vital support furthermore concerns were raised by stakeholders about capacity to meet need and the limited engagement with the complexities of needs are not addressed sufficiently in the policy for cox macdonald 51 the policy proposals lack an understanding of the significance of culture diversity and difference which is necessary to adequately support the mental health of all children and young people in this respect the green paper fails to engage with the strong and wellestablished body of evidence on the social determinants of health that emphasises the multidimensional aspects of inequality in short both the structural nature of socioeconomic inequalities in health and the different types of children likely to be affected by mental health problems are identified by stakeholders as generally absent from the governments framing and contextualisation of the policy pathways thus our analysis of the green paper and consultation process suggests that the social determinants have been at best marginalised in the evidencebase for the policy instead the green paper tends to focus on families as the cause of mental health problems rather than identifying the causes of the causes 16 of health and health inequalities as factors in mental health inequalities among children and young people the green papers emphasis on cost as a key driver for reducing mental health problems in children and a continued refusal to engage with the impact of austerity and cuts on the child mental health system throughout the consultation process reflect a continued commitment to the programme of austerity we propose that problem representations critique in this paper stem from an active disengagement with parts of the social determinants of health evidence base that are less politically and ideologically palatable for the current uk government this is sadly a persistent theme in literature about health inequalities indeed doyal with pennell 13 argued more than 40 years ago that focusing on the individual origin of disease obscures the social and economic causes of ill health and is therefore one way of diffusing the political significance of the destruction of health political knowledge is therefore prioritised over established scientific and practical implementation knowledge 40 justified through particular problem representations 152 a counter narrative illustrated through stakeholder evidence using bacchis 152 framing of problems being discursively created and justified using specific types of politically motivated evidence 40 we identified a counter narrative to that put forward by the green paper by stakeholders with interest and expertise in child mental health that was sidelined by the governments narrative society as a whole has a role to play in demanding an end to the conditions causing health inequalities 14161726 to do so scambler and scamblers 26 argue there is a need to critique and challenge the mechanisms in society that give rise to and sustain inequalities in power and wealth to address the inequalities in health and health care yet our analysis of the green paper and consultation has demonstrated limited engagement with and narrow framing of inequality in relation to child mental health through engagement with the wider discourses on inequalities in the mental health system it seems stakeholders were much more aligned with a social determinants of health perspective and illustrate gaps in the evidence base of the policy our findings and analysis of the responses to the transforming children and young peoples mental health provision green paper 2 from experts and advocates for child mental health illustrate the need for greater commitment to challenging the inequalities present in the childrens health systems this commitment must take account of the interconnections between social determinants including identity and place and how these factors interact with access to and experience of mental health support 1161720 integrating macrolevel structural forces into systemwide approaches are therefore key in conceptualising and addressing the full range of interrelationships identified in a social determinants of health perspective strategies to tackle health inequalities may therefore be more successful when integrating wider aims such as redistribution of wealth via increased taxation or labour market regulation to address health inequalities related to poverty 14 yet such macrolevel sector wide policies which aim to address health inequalities are rare 53 and for soroka wlezien 54 redistribution has relatively low public support generally making a policy intervention from national government less likely the localisation of health spending and responsibility 16 presents opportunities to address some of the gaps in the national policy process highlighted in this review through local policy and strategy where national government leaves gaps in acknowledgement of the social determinants of health and targeting health inequalities at a local level local policy makers may be more able to address health inequalities in an embedded and systemwide way 41 understanding the complexity of inequalities and access needs with specific attention to place may be harnessed at a local policy level where mental health support is available for all but resourcing and delivery of support is targeted based on need local policy makers have a critical role in translating and adapting national policy for their communities and making good any absences and oversights in national policy relation to health inequalities we provide evidence in this paper that local policy makers are already mindful of this task but given the scale and complexity of this work highquality support is needed for local teams to engage with conclusions in light of our findings we argue that transforming children and young peoples mental health provision is imperative to respond to the growing prevalence of mental health problems and inequalities in the context of changes in policy and service provision in recent years and the impact of the covid19 pandemic while the government has set out plans for addressing increasing mental health provision in a number of ways we argue that the approach is limited by significant absences and narrow framings of inequality we suggest that the green paper may have had a stronger focus on the social determinants of child mental health if the stakeholder responses to the extensive consultation had been more meaningfully addressed the illustration of how policy discourse frames and produces problems and the way evidence used is justified politically for example the continued implicit upholding of the necessity of austerity without austerity being explicitly discussed may be of interest to all those hoping to critique and influence policy approaches to health inequalities not just in the context of english policy our novel approach illustrates how using methods from political and social science disciplines can reveal new insights about health policies using a wpr approach to evaluate policy pathways with discourse analysis of policy documents and stakeholder responses highlights the mechanisms through which policies plans are constituted and justified particular narratives choices in evidence bases and highlighted absences produce particular problem representations which lead to particular policy approaches by engaging with wider policy and health system responses counter narratives become evident through which alternative policy pathways can be identified our research speaks to both national and local policy makers and advisors as the effects of problem representation and the complexity and importance of the social determinants of health to understanding child mental health illustrate that health inequalities must be a central focus of health policy embedded in the realities of health systems one of the consistent standout responses from the stakeholders who took part in the consultation the elephant in the room was around austerity one of the major challenges for those responsible for implementing local policy is the realities of overstretched budgets and workforces making changes difficult to achieve we suggest the new child health system in england which involves integrated care systems and sustainability and transformation partnerships provides an opportunity to better tackle mental health problems and inequalities in children and young people additional file 1 table competing interests the authors declare no competing interests

background a national policy for england published in 2017 entitled transforming children and young peoples mental health provision aimed to address the increasing prevalence mental health problems in children and tackle inequalities in the context of this policys implementation as ongoing and the effects of the covid19 pandemic the need for appropriate timely and ongoing national government commitment is vital methods a narrative review using a problem representation evaluation 1 we critiqued the policy and related consultation documents using a social determinants of health perspective we also reviewed wider policy discourses through engaging with stakeholder responses providing an innovative methodological contribution to scholarship on public health policy and health inequalitieswe found absences and oversights in relation to inequalities most notably the lack of acknowledgement that mental health can cause inequalities access workforce capacity and the impacts of cuts and austerity on service provision we suggest these inadequacies may have been avoided if stakeholder responses to the consultation process had been more meaningfully addressed we illustrate how problems are discursively created through the process of policy development justified using specific types of evidence and that this process is politically motivated local policy makers have a critical role in translating and adapting national policy for their communities but are constrained by absences and oversights in relation to health inequalitiesthis narrative review illustrates how policy discourse frames and produces problems and how the evidence used is selected and justified politically this review contributes to the existing transdisciplinary field of knowledge about how using methods from political and social science disciplines can reveal new insights when critiquing and influencing policy approaches to health inequalities

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introduction the united states has been in a period of mass incarceration for several decades with nearly 21 million individuals locked in prisons or jails at year end 2019 1 and more than 10 million admissions to jails each year 2 incarceration is unequally distributed in the us with black men especially those who are poor and with low education disproportionately affected 34 for example at yearend 2017 the imprisonment rate for sentenced black men 2336 per 100000 black male us residents was almost six times that of sentenced white men 397 per 100000 white male us residents 5 almost half of incarcerated men are fathers of minor children with higher percentages among black and latino incarcerated men than white incarcerated men 6 for fathers involved in the criminal justice system recidivism remains a significant challenge as they seek to reintegrate into their families places of employment and communities following incarceration in the present mixed methods longitudinal convergent study we examined 1year recidivism in black fathers of young children in relation to their contact with a focal child relationships with childrens caregivers and family support as well as experiences of separation from children and plans for reunion with children integral to their reintegration we also examined how black fathers maintained their identities as fathers and connections with their families despite the stress of incarceration using a risk and resilience framework and an ecological perspective we focused on jail incarceration because although it is the most common form of incarceration in the us recidivism from jail is understudied especially in the family context incarceration in jails yearend population statistics published by the us bureau of justice statistics indicate that in 2019 1430800 people were housed in state or federal prisons and 734500 were incarcerated in jails across the us 1 jails are local corrections facilities usually run by sheriffs departments or city governments they house those detained awaiting conviction or sentencing or serving sentences for misdemeanor crimes usually for under a year in contrast prisons are state or federal facilities that house those convicted of felonies typically for more than a year yearend or daily population statistics however do not tell the whole story regarding mass incarceration in the us 3 yearly statistics are also an important part of the mass incarceration story more than 10 million admissions to jails occur each year across the country including many individuals who are released and reincarcerated within the same year 78 within jails most people are awaiting conviction or sentencing or unable to post bail indicators of the systemic racism inherent in the courts include black individuals being more likely to experience pretrial detention and having higher bail limits set than white people 49 about 170000 people on any given day are serving sentences for conviction of misdemeanor crimes 2 these are usually lowlevel crimes such as disorderly conduct vandalism trespassing petty theft prostitution public intoxication simple assault reckless driving discharging a firearm or possession of cannabis nonpayment of child support or bail jumping depending on the jurisdiction another substantial reason for jail incarceration is revocation based on violation of the technical terms of parole or probation at least one in four people who go to jail are rearrested within the same year with many of those who return affected by mental illness substance abuse and poverty 310 although mental illness and substance abuse are even more common in jail than in prison a recent paper found that black parents in jail were less likely to show mental illness than white parents in jail 12 suggesting different pathways to incarceration it is unknown however if there are unique pathways to recidivism among black incarcerated fathers mass incarceration whether in jail or prison is a form of systemic oppression in the united states with welldocumented and profound impacts on black families 13 incarceration not only takes a family memberusually the fatherout of the provider role which can lead to family financial instability and material hardship but also burdens families with additional costs such as legal fees court fees cash bail and costs for visits and phone calls 414 incarceration also decreases future economic mobility 1516 moreover often technical violations of the strict rules of probation and parole can lead to reincarceration within a short period of time especially for black men in addition to these issues many black men and women most of whom are parents are incarcerated in jail for relatively brief periods for crimes of povertyunpaid parking tickets nonpayment of courtordered child support unpaid debt or fines or lack of the ability to pay cash bail 318 yet even short periods of incarceration can negatively affect ones ability to pay rent or a mortgage or meet family and state obligations like the payment of child support more arrests and incarcerations can feed into a vicious cycle as it relates to employment family relations and poverty yet amidst these systems of oppression many black families show enormous resilience and willingness to support incarcerated individuals 1419 reentry and recidivism in 2019 alone state and federal correctional facilities released 608000 individuals 20 and 878900 people were on parole or the conditional release of an individual into the community after incarceration while still under correctional supervision 1 about twothirds of individuals released from prisons are rearrested within three years with a 441 rearrest rate occurring within the first year after release 21 although there are fewer studies of jail recidivism one study measuring jail reincarceration within the year following release from jail found a rate of 367 22 recidivism rates among black men are higher than any other ethnic group representing structural discrimination and a depletion of resources available to families and children according to the bureau of justice statistics 25 recidivism measures require three characteristics a starting event such as a release from prison or jail a measure of failure following the starting event such as a subsequent arrest conviction or return to prison or jail and an observation or followup period that generally extends from the date of the starting event to a predefined end date some scholars use reincarceration in prison or jail as the measure of recidivism whereas others use new convictions or arrests or some combination of the above 25 in this study we use new convictions within 1 year of release from jail because this information was readily available using state consolidated records systems although being a parent is not consistently related to rearrest and reoffending children often provide motivation for parents to succeed during incarceration and reentry 42627 previous research has found that individual predictors of recidivism include age race gender marital status educational attainment number of prior convictions and employment 2829 so these are important factors to consider in studies of recidivism and reintegration however child and family factors are important for incarcerated parents during incarceration and reentry as well including parentchild contact during incarceration and family support 30 in terms of methodological approaches several studies have used an integrated mixed methods design which supports the use of qualitative and quantitative methods for the purpose of hypothesis testing and hypothesis generating on reentry for youth and adults 3132 such as the method that we are utilizing in this study child and family factors in addition to its relation to the literature on incarcerated fathers the present study may also be relevant for the wider literature on black fathers the social construction of black fatherhood has progressed through various phases over the last two centuries of american social history evidence of responsible black fatherhood behavior is well documented during the time of chattel slavery 3334 furthermore despite recurring barriers postslavery which included the lingering effects of historical institutionalized and legalized racism black fathers were engaged in adaptive ways to serve as an active parent to their children 3536 more recent research on fathers and families consistently reveals that most black males want to be present and involved fathers in fact the most recent literature highlights that role flexibility is most relevant for black biological and social fathers including the establishment of setting firm guidelines in the context of a close warm and nurturing fatherchild relationship 37 38 39 a growing number of scholars who have examined how incarcerated individuals fare during reentry from prison have found that family support is critically important one such investigation is the returning home study conducted from 2001 to 2006 by the urban institute to document incarcerated individuals reentry following release from prisons in several states in an analysis of returning home data the researchers found that 80 of those who reentered the community from prison felt that family was an important factor in helping them to stay out of prison 41 family members provided multiple supports including emotional instrumental housing and financial support and they often helped the formerly incarcerated individuals find employment 41 in addition fathers who were more engaged in their childrens lives 3 months into the reentry period also were less likely to recidivate or violate the terms of their parole 42 they also reported fewer depressive symptoms and worked more hours per week than fathers who were less engaged with their children suggesting better integration into the community and family according to the centers for disease control and prevention black fathers are the most engaged with their children across a range of involvement activities compared to us american fathers of other races 9 a key predictor of engagement in childrens lives among incarcerated black fathers was how much contact the father had with the child during the prison stay 42 another more recent study that focused on returning fathers is the multisite family study on incarceration parenting and partnering which was conducted as part of federal demonstration programs focusing on incarcerated fathers family involvement nearly 1500 fathers and their female partners were followed longitudinally the researchers found family support was critical in helping fathers adjust in the community although postrelease supervision practices and policies did not support incarcerated fathers families 30 again fatherchild contact during incarceration was important in helping fathers adjust to family life following reentry in an analysis of a subset of fathers who provided interviews researchers found that fathers were more likely to live with and financially support their children upon release when children were younger there was more fatherchild contact during incarceration and when the fathermother relationship was more positive 43 investigators found that among the individuals reentering their communities in the boston area following a prison incarceration family of origin support was important for success 19 westerns study although not specific to incarcerated parents but included many incarcerated parents indicated that female relatives such as mothers and sisters were particularly supportive during reentry for the reentering parents in the study caregivers of children did not play a significant supportive role but rather served as gatekeepers of parental contact with children the role of fathers relationships with the caregivers of their childrentypically childrens mothers or grandparentsremains to be seen regarding reentry success in addition to these large studies smaller studies have also investigated paternal experiences of reunion with their children for example in a qualitative study of 19 fathers who had at least monthly contact with their children and who had been released from prison in the past year investigators found that fathers felt deeply committed to their children even though they experienced multiple reentry challenges associated with poverty and inequality during reentry 26 in another qualitative study researchers interviewed 10 african american fathers reentering the community following a prison stay and found themes related to unaddressed childhood trauma low selfesteem and selfworth and family reunification 44 all the fathers discussed reuniting or enhancing their relationships with their older children because those were the relationships they felt needed the most work 44 however barriers often existed regarding their access to younger children especially conflict with the childs caregiver who regulated access to the child only a few studies have been conducted on recidivism or reentry when a father is in jail despite the pervasiveness of jail incarceration in one exception the vera institute of justice conducted the close to home project examining incarceration and reentry in relation to family factors for three jails 45 they found that the family relationships of jailed individuals 67 of whom were parents were important most individuals incarcerated in jails similar to those in prisons relied on family support during their incarceration and during reentry into the community 445 the limited research focusing on reentry for parents incarcerated in jails means that it is unclear whether or how childrens caregivers or other family members maintain family connections during incarceration including fatherchild contact or if this is predictive of recidivating or not recidivating following release from jail theoretical framework we apply a risk and resilience framework 46 that examines risks and protective factors related to positive outcomes for individuals living with significant risk within the ecology of the family and other social environments in which human beings develop and interact resilience in black men and specifically for lowincome black fathers following incarceration is a largely understudied phenomenon even though incarceration remains a major risk for lowincome black men in fact the ongoing inequities segregation and discrimination that are at the core of the history of black people in the united states continue to inform institutions and structures that are vital to life and mobility informed by these conditions incarceration is an existential risk for lowincome black men 47 understanding the factors associated with positive outcomes for formerly incarcerated fathers is an important consideration for improving how us american systems of justice interact with this population and how children and families can be supported through this experience while the literature on paternal incarceration explores how fathers incarceration disrupts and negatively affects the family and specifically children through financial hardship loss of emotional support and loss of a parent support from the family may also have effects on black fathers who are incarcerated 14 the risk and resilience framework proposes that assets and resources play critical roles in lessening and sometimes nullifying the effects of risk exposure 4648 such as incarceration and negative institutional contact we conceptualize family support as a resource for black incarcerated fathers moreover we expect that resources like quality of the coparenting or caregiving relationship and family support could enhance father motivation and intention to engage with their children this interplay of assets and resources in the face of significant risk may reveal important associations for decreasing recidivism family support is a resource that enriches resilience in black men who were formerly incarcerated one key component of resilience in this population is the creation of ones own supportive environment 49 immediate family and close friends are often the core of these support networks which improve the odds of positive outcomes and provide resources for managing the stress of living in a racially discriminatory and unfair system that limits access to success or mobility 50 in fact in studies of black mens resilience participants often identify stressors and challenges like incarceration racial microaggressions employment difficulties and navigating their difficult neighborhood conditions as the main risks to positive outcomes however they identify internal assets like perseverance selfreflection and a determination to overcome as contributing to their overall resilience in the face of these risks 4951 black men also identify religionspirituality and support from key social networks like family and friendships as pivotal to their resilience 495052 the criminal justice system has historically been unjust and unequal in its treatment of black men where in the united states they are 62 times more likely to be incarcerated compared to white men 47 black incarcerated fathers however also exist in the social ecology of their families appending a socioecological framework 53 to this study allows for an appreciation of the intersecting challenges that black men face within their communities while also centering the critical roles that social resources like family support play in improving the odds of success for black men in lowincome contexts this ecological perspective of resilience accounts for the traditional links between the individual and environmental risks but also brings to focus the links between the individual community and other social levels 505455 research suggests african american fathers are often met with structural and institutional barriers that inhibit their opportunity to financially support their children 56 poor fathers will often transform their ascribed role as the breadwinner into a more accessible and achievable role such as being a caretaker of their child it has been suggested that a more fluent and inclusive term is needed to capture the essence of the fathering role 57 as these roles of caretaker or breadwinner are further compromised by the shock of an incarceration unfortunately in general black men are rarely studied as parents and when they are it is often as absent fathers this research illuminates the need for additional research that documents the fathering experience of incarcerated black men in jail without highlighting the welldocumented structural disadvantages of black male identity in the united states and without accounting for the historical and enduring inequities in how us american systems of justice police the bodies of black men we would miss a major element of the story of black fathers who are incarcerated against this narrative backdrop we focus on the stories of incarceration and child nurturing told from the perspectives of black fathers recognizing how incarceration and other justice system experiences create stratifications within the black community 5859 we focus on fathers employment as a key resilience factor in understanding the impact of incarceration on black fathers a bureau of justice statistics report indicates that the rate of imprisonment among black americans has dropped by 34 since 2006 20 though young and less formally educated black males are at greatest risk of incarceration and thus at the lower end of the social strata in black communities our study therefore features the stories and experiences of black fathers who are incarcerated and centers on their resilience through a socioecological focus incorporating resources and assets related to their postincarceration outcomes the current study in the present longitudinal mixed methods convergent study we focus on black fathers who were incarcerated in jail during the initial data collection we enrolled fathers with young children for three reasons first most experiences of parental incarceration occur before children are 9 years of age 60 second researchers found that when children were younger fathers had an increased chance of living with and financially supporting their children following paternal release from prison 3043 third fathers in the criminal justice system who have young children are understudied especially during reentry 27 thus in the present study we include fathers who had at least one child between 2 and 65 years of age at the time of the initial data collection additionally one of their children was randomly selected for participation in the study we focus on black fathers in jail because of racial disparities in the criminal justice system high recidivism rates and because jail is the most commonalbeit understudiedform of incarceration in the us thus filling a gap in the literature we include a qualitative component to the study to further explore fathers experiences of separation from children during incarceration their identities as fathers and plans for reunification with children to expand on factors that occur during incarceration that can be important during the reintegration process research questions the study addresses the following questions 1 how do black fathers experience fatherhood in the context of incarceration and does this relate to their plans for reunion with their children following release 2 what is the rate of new convictions and incarcerations for this sample of black fathers with young children 1 year after the fathers reentry from jail 3 does frequency of fatherchild contact mediate the relation between fathercaregiver relationships and not recidivating and is this indirect effect conditional on other factors we examined childrelated variables family variables individual variables and systemrelated variables in our quantitative analysis we hypothesized that fathercaregiver relationship quality and family support would interact in predicting frequency of fatherchild contact during incarceration we also hypothesized that frequency of fatherchild contact would mediate the relation between fathercaregiver relationships and not recidivating controlling for demographic variables preincarceration employment mental healthsubstance problems and whether or not the father was incarcerated for not paying child support we expected the indirect effect to be conditional on whether or not the father planned to live with the child following release with stronger associations expected when fathers planned to live with their child methods research design this study is a longitudinal mixed methods study that utilizes a singlephase or convergent mixed method design involving the separate collection and analysis of quantitative and qualitative data for us to best understand the phenomena utilizing this design for the research provides us with the opportunity to merge the two data sources by bringing the separate results together for ease of interpretation and facilitation of a more integrated analysis 61 it was our intent to relate the quantitative results to the qualitative findings which reflected the strengths of our research team sample the sample was drawn from a larger multimethod multirespondent study of incarcerated parents with children between 2 and 65 years of age from the larger study 86 fathers were black or biracial with biracial fathers identifying as black and one other race two of the fathers were still incarcerated for the same conviction as when they were initially assessed in jail they were excluded from this report the remaining 84 fathers ranged in age from 18 to 46 with a mean of 293 years their education ranged from 9 to 16 years with an average of 123 years most fathers reported that they had never been married whereas others were married or divorced they had served an average of 457 days in jail with primary and secondary offenses listed in table s1 in supplementary materials the most common offense was a revocation for a technical violation of the terms of parole or probation and the second most common offense was nonpayment of child support in addition less than 1 in 10 of fathers in the sample was incarcerated for a first offense with the number of prior arrests ranging from 0 to 52 with a mean of 89 preincarceration annual selfreported income ranged from 0 to 115200 with a mean of 13669 median of 9564 and mode of 0 fortythree of the focal children were girls 643 of fathers lived with their children prior to incarceration and 643 of fathers planned to reunite with their children following incarceration in addition 726 of fathers had retained legal custody of the focal child and none of the fathers had their parental rights terminated procedure recruitment efforts began with the jailed parent weekly jail administrative staff provided either the names of newly sentenced parents who had children between 2 and 6 years of age or access to a database with this information we identified incarcerated parents who then participated in a brief initial screening with a trained researcher to determine if they met research criteria indicating that they were at least 18 years old had a child who lived with kin within the county in which the incarcerated person was serving time had retained legal rights to the child and had not committed a crime against the child had cared for the child at least part of the time prior to incarceration could understand and read english and had already been sentenced to serve jail time or were charged with committing a misdemeanor crime that would result in jail time for this analysis we focused on black fathers if the incarcerated parent had more than one child in the age range one child was randomly selected for participation incarcerated parents who met criteria were invited to participate in the study and those who agreed signed informed consent forms and participated in an interview and selfadministered questionnaires for about half of the families children and childrens caregivers also participated in the study 62 at initial enrollment and at 1 year following release we examined public court records in the state in which data were collected to determine the initial offense and subsequent recidivism the study was approved by the institutional review board from our university and a national institutes of health certificate of confidentiality was used we were unable to compensate incarcerated parents due to jail policies two jails were sources of enrollment for this sample both of which were run by county sheriffs departments the first jail from which we recruited fathers is in a large urban community other incarcerated fathers were enrolled from a second jail in an urban community that holds a mix of individuals from urban and rural locations both jails disproportionately incarcerated black individuals relative to the states racial demographics these characteristics are similar to other jails in the midwestern region of the united states measures descriptive statistics for each measure are shown in table 1 demographic and family information based on prestudy interviews with incarcerated fathers we collected selfreported information about paternal age race education number and ages of children preincarceration income hours of work per week current offense length of incarceration prior arrests and incarcerations and previous mental health and substance abuse problems most fathers had been incarcerated previously most often for short stays in jail although 18 fathers had served 18 months or more in prison for those who had a sentence while in jail sentences ranged from 5 days to 1800 days this range includes the original sentences for the 24 fathers in jail on a revocation twenty fathers in the study were awaiting sentencing fathers had been separated from their children because of this incarceration between 15 and 450 days with a mean of 70 days excluding fathers who were in jail on a revocation the modal length of separation was 14 days the focal children ranged from 1 year to 65 years at separation from fathers we asked fathers if they had lived with the focal child right before their current incarceration and if they planned to live with that child following release in addition we asked fathers multiple openended questions including what was the separation from your child like for you at first how are you doing with it now what was the separation like for your child and how is your child doing now what is the most difficult part about separation from your child do you receive visits from your child if so how often who brings the child if not why not do you talk on the phone with your child if so how often what are your plans for reuniting with your child responses were written down as close to verbatim as possible because the jails did not allow audio recording of interviews interviewers used prompts if the respondent did not initially answer the question responses were analyzed using a grounded theory approach fathers also shared information about their preincarceration employment 50 fathers were employed prior to incarceration with 35 being employed at least fulltime or even working more than one job and 15 having parttime work jobs ranged from administrative or clericalsales work to skilled manual employment to machine operation or unskilled work one father did not report his occupation recidivism we used the circuit court access system that contains public records of criminal convictions and incarcerations to look up individuals at the time of study enrollment to determine their offense and 1 year following their release from jail we used new convictions as the measure of recidivism we recorded new incarcerations and community supervision fatherchild contact frequency of fatherchild contact was coded from interview questions during the fathers time in jail we asked how often the child visited in one question and how often the incarcerated father talked to his child on the phone in another question some fathers provided a weekly average however some fathers said 1 time per month or 1 time since i was incarcerated we combined the information from visits and calls into a total contact score as they were significantly correlated r 0314 p 0004 we did not include written correspondence due to the young age of focal children weekly averages for phone calls with the focal child ranged from 0 to 7 weekly averages for visits ranged from 0 to 3 about 60 of fathers did not receive visits from the focal child for some fathers this was their choice but for others it was because of factors outside of their control approximately 42 of fathers did not talk with the focal child on the phone however the types of contact were compensatory to some degree with 72 of fathers receiving visits or phone calls with the child total contact ranged from 0 to 9 callsvisits per week due to the somewhat skewed distribution of the total contact variable we used a square root transformation in analyses for the 34 focal children who visited their fathers in the jail most were accompanied by their mothers about 20 of children were brought by grandparents aunts uncles or other extended family members and less than 1 were brought by the fathers new partner family support to evaluate family support we used the family subscale of the multidimensional scale of perceived social support 64 statements referring to the family are rated on a 1 to 7 scale with higher numbers indicating more agreement with the statement the four statements about the family include my family really tries to help me i get the emotional help and support i need from my family i can talk about my problems with my family and my family is willing to help me make decisions respondents were also asked to list their relation to the family member who fulfilled the type of support assessed fathers scores ranged from 4 to 28 on the family subscale and they most often listed their mothers as supportive family members although listing multiple family members was also common the mspss has good psychometric properties 65 cronbachs alpha for the family subscale was 090 in this sample fathers feelings about childrens caregivers the inventory of family feelings 66 was used to assess fathers perceptions of relationships with their childrens caregivers the iff is a 38item selfreport measure of interpersonal affect that shows patterns of conflicted relationships and warmth or closeness in dyadic family relationships the iff has high reliability good construct and concurrent validity and has been used to index quality of relationships between spouses parents and children and other family members scores range from 0 to 38 with higher scores indicating more positive affect including warmth loyalty trust and respect toward family members and lower scores reflecting conflicted relationships the iff was chosen for this study because it has been used with incarcerated parents previously 6268 and it is one of few measures that applies to a variety of family relationships in this sample 89 of focal children were living with their mothers but 11 lived with a grandparent or aunt or uncle fathers iff scores regarding their childrens caregivers ranged from 0 to 38 cronbachs alpha for the iffcg in the present study was 089 alcohol and substance use the michigan alcoholism screening test was used to assess incarcerated fathers selfreported alcohol abuse in the previous 12 months 69 twentyfive items comprise the measure scores range from 0 to 53 with higher scores indicating higher risk of alcohol abuse in the current study the mast had a cronbachs alpha of 089 the drug abuse screening test was used to assess incarcerated fathers selfreported drug abuse in the previous 12 months 70 twenty items comprise the dast scores range from 0 to 20 with higher scores indicating more drug abuse severity in the current study the dast cronbachs alpha was 093 on the mast 44 fathers were characterized as having no alcohol problems whereas 8 showed borderline problems and 32 showed evidence of alcohol problems on the dast 39 fathers were characterized as not having a drug problem whereas 45 showed evidence of drug problems plan of analysis qualitative analysis we analyzed the openended responses using a grounded theory approach as this was a secondary data analysis the interview questions did not change throughout the process as they would if using traditional grounded theory methodology 71 the analysis was completed using nvivo 12 we began by creating open codes based on memos created after reading fathers responses to the questions how did you adjust to the separation at first how are you adjusting to the separation now how did your child adjust to the separation at first how is your child adjusting to the separation now and what are the most difficult parts about being separated from your child these responses elicited 55 open codes as these codes were analyzed and higher order codes and themes began to emerge we brought in responses to an additional eight questions to continue the analysis these questions are who is your child with now was this your choice are you satisfied with the arrangement how did you decide on this person once the open codes were established we continued with the grounded theory method of organizing and arranging the codes into selective and eventually theoretical codes this process involved additional memoing and visual concept mapping the memoing process or running notes allowed us to create an iterative record of our thoughts while engaged in active coding including documenting ideas feelings and a rationale for the coding we also used the memos as the basis for discussion among study team members the process for dealing with discrepancies and reaching consensus during the feedbackreview sessions was initially done by the primary analyzers as explained in the previous paragraphs the primary analyzers reviewed the memos and held discussions regarding the patterns that were emerging for theory building when disagreements occurred it provided an opportunity to rereview memos and create summary memos and reach consensus on the concepts subsequently two additional researchers engaged in the process when dealing with a few lingering discrepancies to reach consensus during our feedback and review sessions quantitative analysis we began by reporting descriptive statistics about fathers recidivism subsequently we evaluated a moderated mediation model using hayes process macro v35 74 model number 61 executed in spss v26 75 we evaluated the indirect path from fathercaregiver relationship quality to the outcome recidivism via the mechanism of contact with the focal child we also examined two moderators paternal plans to coreside with the child following incarceration and family support the process macro mean centers continuous variables used in the construction of interaction terms and generates 10000 bootstrapped samples to calculate 95 biascorrected confidence intervals interactions significant below the p 010 level are examined at multiple levels of the moderator and tested for significance the process model also estimates regression coefficients of all direct and indirect paths using ordinary least squares regression for continuous outcomes and binary logistic regression for the recidivism outcome also using 10000 bootstrapped samples to calculate 95 biascorrected confidence intervals the model also examined effects of paternal preincarceration employment in relation to recidivism we controlled for alcohol problems drug problems and whether the current incarceration was for nonpayment of child support we selected these covariates because they were theoretically related to and were correlated with the mediator or the outcome we assessed additional covariates but rejected them because they did not relate to the outcome or mediator or they were too highly correlated with other similar predictors reported effects were characterized as small moderate or large using cohens benchmarks 76 power analyses for the multiple regression and logistic regression analyses conducted using gpower 31 7778 are reported below results how do black fathers experience fatherhood in the context of incarceration and does this relate to their plans for reunion with their children following release the findings of the qualitative analysis that address the first research question are organized into three themes that demonstrate the ways in which fathers experienced fatherhood while simultaneously experiencing separation due to incarceration these themes represent three distinct fatherhood identities father as nurturer father as protector and father as provider throughout the results section pseudonyms are used in place of participant names to protect confidentiality father as nurturer throughout the interviews the most frequently referenced fatherhood identity was father as nurturer this theme broadly encompasses the open code to be there for many of the responses reflected the idea of simply wanting to be there for the child the family the special experiences the routine moments this includes simple aspects of daytoday life such as hearing their children talk to them for example one father said that he felt particularly connected to his daughter when she says daddy and that he missed this simple statement during incarceration hearing his young daughter call him daddy made him smile and feel positively about his role as a father and he looked forward to being able to experience such interactions following release from jail anticipating such interactions with his daughter also helped provide motivation to stay out of jail from this selective subcode we see one of the primary ways that fathers experienced their physical separation from their children this subcode reflects the importance that fathers placed on simply being present in their childrens lives one father kaenan summed this up succinctly when discussing the most difficult part of the separation not waking up seeing her every day not seeing her get ready for daycare every day putting her hair in a little ponytail from these responses we see the value that fathers assign to their ordinary daytoday interactions with their children routine interactions were cited throughout the interviews as the experiences fathers missed most during incarceration and as what they were most looking forward to engaging in postrelease another father concisely explained the importance of this nurturing connection when discussing his release plans just being a dad waking up and seeing my son every day father as protector the second distinct fatherhood identity that emerged from the interviews was the idea of father as protector this identity was highlighted in two ways throughout the interviews the first was aligned with a traditional understanding of the ways in which fathers act as emotional security and physical protection from potential dangers this idea was most prominent when fathers referred to childrens living arrangements during paternal incarceration including wanting to protect children from harm or mistreatment within this identity we see the ways in which the justice system interacts with a fathers perception of their role within their childs life when fathers were dissatisfied with the childs current caregiving situation they expressed acute concerns regarding their childs safety and wellbeing for example reflecting on his concerns for his daughter one father darius responded who shes around the company her mom keeping im always worried about it its my daughter im mad i cant be there for her when fathers expressed satisfaction with the childs caregiver concerns were more general and broadly encompassed childrens health academic achievement and happiness for example when asked about his concerns for his daughter during his incarceration a different father levell responded just not being there as a parent my only concerns are about me not being around no general fears just a lot of what ifs shes got the best mom in the world shes so strong it is important to note that in many cases the fathers view of the mother as a caregiver was separate from their partner relationship for example levell who is quoted above reported lower than average responses for his relationship with the childs mother however he still viewed her as a positive influence in his childs life the second distinct demonstration of father as protector was through fathers protecting their children from the justice system and habituation towards carceral settings most commonly fathers showed this protection by foregoing visits from their children during incarceration the interviewees demonstrated a pervasive belief that interacting with their children in the jail may lead to their children becoming habituated to the carceral setting and therefore make them more susceptible to criminal justice involvement one example of this pervasive sentiment is demonstrated by one father george when asked why he did not receive visits from his son he responded by saying i dont want him to see me this wayi want him to be on a different pathi dont want him to become comfortable with seeing me in jail another father directly related his own experience of paternal incarceration to that of his sons by saying i dont want him herewhen i was growing up i saw my dad through the glass in addition to selfdistancing some fathers talked about the ways in which childrens caregivers acted as gatekeepers of fatherchild contact this gatekeeping was primarily related to poor fathercaregiver relationships including nocontact orders additionally some caregivers purposefully kept children from the incarcerated fathers in an attempt to protect them from both the criminal justice system and confusion of seeing their father incarcerated father as provider throughout the interviews many fathers discussed the importance of acting as the financial provider for their children and family however within the context of incarceration many fathers were unable to continue as primary financial providers and were therefore stripped of that identity within the analysis many of the fathers who spoke of their roles as providers did so in a way that highlighted their current inability to fill this role in their families however many fathers remained hopeful about resuming the role as provider in the future for example one father james said ill get released in a week so that leaves me 20 days to get a job and a paycheck so i can get her a birthday present if i cant do that it will be a real depressor in addition many fathers showed a desire to be the provider through their plans with their families after release such as plans to help their families become financially stable and plans to take their children on trips we see this through one fathers rachards description of his plans immediately following his release i was hoping to have enough money to take her to disney world or some place ive been gone a long time so ill take her to do something fun what is the rate of new convictions and incarcerations for this sample of black fathers with young children 1 year after the fathers reentry from jail to address the second research question we recorded new convictions and new incarcerations in this sample 369 of fathers had a new conviction within a year following release from jail which is our measure of recidivism in this study about 107 had a new incarceration related to the new conviction overall 631 of fathers had no new conviction in the first year in addition to the 369 with a new conviction another 83 had an open criminal case does frequency of fatherchild contact mediate the relation between fathercaregiver relationships and not recidivating and is this indirect effect conditional on other factors we conducted two analyses to answer the third research question a multiple regression analysis examining predictors of fatherchild contact and a logistic regression analysis using new convictions as a measure of recidivism predictors of contact with children the analysis predicting frequency of fatherchild contact during incarceration was statistically significant r 2 0437 f 6387 p 0001 with a moderate to large effect power for the overall effect size of 0413 given the sample size and number of predictors assessed was 0994 for this analysis fathers who planned to live with their child after incarceration received more calls and visits during incarceration p 0010 moreover there were three statistically significant interactions the x w interaction resulted in an r 2 change of 005 f 6537 p 0013 the x z interaction resulted in an additional r 2 change of 006 f 7590 p 0007 while the x w z interaction resulted in an additional r 2 change of 013 f 8301 p 0001 tests of the x w interaction revealed that when fathers planned to live with their child following release positive fathercaregiver relationships were associated with more fatherchild contact during incarceration p 0001 however when fathers did not plan to live with the focal child after incarceration there was no association between fathercaregiver relationships and fatherchild contact p 084 tests of the x z and x w z interactions indicated that when fathers planned to live with the focal child and received average or high levels of family support positive fathercaregiver relationships were associated with high levels of fatherchild contact p 001 when fathers did not plan to live with their children fathercaregiver relationship quality was unrelated to frequency of fatherchild contact butimportantlyfamily support predicted contact frequency p 005 the only other significant predictor of fatherchild contact was child support fathers who were incarcerated because of nonpayment of child support were less likely to have contact with the focal child during incarceration compared to fathers who were incarcerated for other reasons p 0001 at the bivariate level nonpayment of child support was unrelated to coresidence prior to incarceration or plans for coresidence following incarceration however predictors of not recidivating although the logistic regression model predicting the probability of not recidivating was not statistically significant p 0071 with the pseudo r 2 statistics showing a small to moderate effect individual variables reached statistical significance power for the overall effect size of 0180 given the sample size and number of predictors assessed was 0781 for this analysis paternal preincarceration employment related to increased odds of not recidivating p 0037 fathers who were employed just prior to their current incarceration were less likely to experience recidivism during the first reentry year although the wald χ 2 statistic of the interaction between whether the father planned to live with the child following incarceration and fatherchild contact only trended toward significance p 0059 we explored the potential conditional effect to see if it is similar to past research and to inform future research exploratory tests of the interaction showed that when fathers planned to live with the focal child more fatherchild contact was related to less recidivism however when fathers did not plan to live with the focal child more fatherchild contact was unrelated to recidivism qualitative and quantitative findings are integrated in table 3 four key findings were supported by both the qualitative and quantitative analyses including father as provider for his children and family father as nurturer of his child father as the childs protector from the criminal justice system and the importance of fatherchild contact and family support regarding the first theme fathers indicated that they are motivated to work provide for their families and treat their children being employed prior to incarceration may make it easier for fathers to find a job following incarceration in jail thus decreasing recidivism after their jail stay and allowing them to enact their motivation as providers the second theme reveals that fathers want to care for and nurture their children and thus one of the most difficult parts of incarceration is separation from their children fathers indicated that having children provides motivation for lower recidivism in the future one way that fathers can care for and nurture their children during incarceration is to have contact with them through visits and phone calls although quantitative results did not support a link between fatherchild contact and recidivism the third theme reflects the common concern of many incarcerated fathersthey did not want to expose their children to the carceral environment because of fear of intergenerational patterns of incarceration these fathers often sacrificed seeing their children during visits however many of the fathers who preferred that their children did not come to the jail were able to talk on the phone to their children regularly instead the final theme reflects that incarcerated black fathers are dependent on childrens caregivers and other family members to facilitate contact with children fathers ability to stay in touch with their young children during incarceration depended on the willingness of childrens caregivers and fathers extended family members to bring children to visit or facilitate phone calls when fathers planned to live with their children during reentry positive relationships with caregivers and family members were important when fathers did not plan to live with their children during reentry support from extended family appeared to help fathers bypass the gatekeeping role of childrens caregivers thus highlighting the critical role of family support networks integration of results fathers spoke about their desire to act as primary financial providers for their family i want to get a job to get my family on my feet take them to the park play games with them father as provider for child and family many fathers postincarceration plans involved purchasing items for their children or taking them places ill get released in a week so that leaves me 20 days to get a job and a paycheck so i can get her a birthday present if i cant do that it will be a real depressor paternal preincarceration employment related to increased odds of not recidivating in the first reentry year fathers were motivated to work provide for their families and treat their children to positive experiences employment prior to incarceration may also make it easier to find a job following incarceration in jail thus facilitating lower recidivism integration of results fathers spoke about their children as primary motivators for not reoffending just make up for lost time you know never leave my son again hopefully visits during incarceration helped some fathers stay connected to their children as they planned for release i kind of know when im getting out so its a weight lifted off my shoulders now i have contact visits so its a lot better there was a significant correlation between the father as protector code and frequency of childrens visits to the jail there was no correlation between father as protector and frequency of phone calls father as fathers who were concerned about exposing their children to the carceral environment sacrificed seeing their children however many of them were able to talk on the phone to their children regularly instead for many fathers making plans to rejoin their familys daily routines was an important piece of their coping with their incarceration note we integrated quantitative data and qualitative data in this table to provide a more comprehensive description of our findings across different methods discussion mass incarceration in the united states has disproportionately impacted black communities as more than half of incarcerated men are fathers of minor children 6 these overrepresentations within carceral settings demonstrate structural inequality within the justice system as well as a pervasive depletion of resources available to families and children within black communities however despite oppression from the negative sequelae of incarceration many black fathers maintain engagement with their families throughout their detainment and reintegrate into family life upon release in this study we used a longitudinal mixed methods convergence approach to better understand the experiences of 84 black fathers of young children the purpose of the study was to qualitatively examine the ways that black fathers expressed their fatherhood identity in the context of incarceration and to quantitatively assess rates and predictors of recidivism within the sample both qualitative and quantitative analyses were designed to inform our understanding of potential factors that may facilitate reintegration in black fathers with young children our inquiry applied a risk and resilience ecological perspective to help contextualize the experience of fatherhood within incarceration and reentry as we stated previously the role of fathering is a social construction and multifaceted 79 several scholars have documented research on black fathering as mirroring the existing literature on fathering in general whereas some scholars support the notion that for black fathers economic security is fundamental in their ability to become fully engaged fathers 80 recent scholarship on black father identity and incarceration highlights how prison or jail can interrupt the paternal identity process and enhance maternal gatekeeping but potentially strengthen some family relationships 81 82 83 84 our research contributes to the limited research on incarcerated black fathers and their paternal identity and involvement with their children a particularly compelling qualitative finding from this sample highlighted the importance of extended family support as a resource during black fathers jail incarceration and its connection to fatherchild contact consistent with our theoretical model moderate to high levels of family support helped fathers to remain engaged with their families during the incarceration period through visits and phone calls with children interaction analysis showed that when fathers planned to live with their child and received average or high levels of family support positive fathercaregiver relationships were associated with high levels of fatherchild contact additionally when fathers did not plan to live with their children the relationship between the father and caregiver was unrelated to the frequency of fatherchild contact however family support still proved to be impactful in predicting contact frequency these relationships may become even more complicated when fathers return to the community and the mothers of their children have repartnered or engage in gatekeeping access to childrenrelationship quality and coparenting thus are critically important 19 these findings add to the work of many scholars who have demonstrated the importance of family support during incarceration and reentry 1940 including reentry from jail 45 through documenting various pathways of support and inclusion of fathers during confinement whereas these results demonstrate how extended family support is related to the frequency of fatherchild contact quality of the fathercaregiver relationship remained salient in terms of caregivers acting as the gatekeepers of young childrens contact with incarcerated fathers which has been documented previously 85 numerous fathers talked about wanting to see their children during their incarceration but not being able to because the childrens caregivers typically childrens mothers would not bring them to the jail depending on the circumstances and family dynamics these gatekeeping efforts could be circumvented by other family members especially childrens grandparents fatherchild contact during incarceration is important because it helps fathers to stay engaged in their familys lives as well as retain their fatherhood identity during interviews with fathers the most prominently expressed identity was fathers as nurturers whereas historically mothers have been described as the primary source of care and comfort for children our findings contribute to the developing narrative of black fathers as conurturers even within the oppressive context of incarceration 87 as fathers in the study reflected on the most difficult parts of their incarceration many of them referenced the ways in which they miss being there for their child and partaking in the simple daytoday activities of their family such as hearing children call them daddy daily and feeling connected to their children for many fathers reengagement in these routine activities served as the primary motivation for successful reentry additionally many fathers spoke of their visits with their children as a way to cope with the overwhelming loss of routine contact with them during incarceration visits and phone calls with children helped fathers retain their identity as nurturers and carry it forward as they rejoin the family which is important when considering longterm successful reentry our quantitative findings indicated that frequency of fatherchild contact was not directly related to recidivism in the first reentry year however exploratory analyses of a statistical interaction indicated that when fathers planned to live with the focal child after release more fatherchild contact during incarceration related to less recidivism the results are partially consistent with previous research 3042 which found that fatherchild contact during incarceration was a key predictor of paternal engagement in the childs life as well as general adjustment after release from prison in addition the tie to black incarcerated fathers description of themselves as nurturers of their children is novel in addition to fathers as nurturers many fathers expressed their identities as protectors of their children the positionality of being both a father and an incarcerated man was prominent within this identity in that many fathers felt it was their duty to protect their children from the justice system even when this entailed the selfsacrifice of not being able to see them during their incarceration the risk and resilience theory often refers to this modulating behavior as an asset managed by ones internal control to succeed our qualitative results showed that many fathers chose not to receive visits because they were concerned about intergenerational cycles of criminal justice involvement many fathers were concerned that even visiting the jail setting could habituate their children to carceral settings and therefore increase their likelihood of future criminal justice involvement these qualitative findings were reinforced by our quantitative findings which showed that when fathers expressed their primary identity as a protector they received less inperson visits yet they still stayed in contact with their children through phone calls this is a novel finding that contributes to the literature documenting the identity alterations experienced by black fathers who are incarcerated the final theme that emerged in our findings involved fathers as financial providers for their families throughout the parenthood literature many fathers strongly identify as the primary providers or breadwinners for their families this is an identity that has been afforded to many fathers through a history of maledominated workspaces and wage gaps between male and female workers 90 within our study the fathers actually experienced adverse work situations through employment disruption due to incarceration lack of employment opportunities due to prejudices of criminal records and less work opportunity due to racial discrimination in the workplace 15 these adverse conditions make it incredibly difficult for them to fulfill their desired role of father as provider our qualitative results bolstered these welldocumented findings as many of the fathers spoke about their desire to financially support their familys daytoday living expenses as well as special family trips and presents for their children our quantitative findings show that even in the context of this extreme financial adversity these fathers demonstrate resilience paternal preincarceration employment had an inverse relationship to the likelihood of recidivism within the first year of reentry employment prior to incarceration may make it easier for fathers to find employment upon release as it establishes a work history and experience as well as strengthening the provider role which could facilitate lower recidivism through increasing financial wellbeing and community integration limitations one of the limitations of the study in addition to the small sample size limited power to detect small effect sizes and lack of generalizability was that we were not able to collect child data or father interview data at the 1year followup we only had access to paternal recidivism data as measured by public records at that time point future studies should examine the reentry process and the effects of parental recidivism on children at different ages and should make use of nationwide recidivism data in addition recidivism can be defined in many waysin this study that involved a jail sample we chose to use the indicator of new convictions as our measure of recidivism future research should consider using more than one indicator of recidivism and include data about crimeless revocations in addition we did not have access to call logs or visiting records at the jail so we were not able to confirm fathers reports of phone calls and visits with children however corrections facilities generally do not record childrens visits or calls but rather record the adult call or visit with the adult who is supervising the child in the future it may be helpful to also include the reports of childrens caregivers when collecting data about child visits and calls we were unable to audio record interviews in the jails and thus it was difficult to record indepth interview data with incarcerated fathers as fathers responses needed to be recorded by hand an additional limitation to the study is that there were no member checks incorporated in the analysis of the data because it was a secondary data analysis therefore it was difficult to locate the informants for the purpose of member checking our limited access to administrative data and informant family members reduced our ability to conduct triangulation future research should attempt to collaborate with jails or prisons that allow use of audio recording moreover families are often complex with multiple children and caregivers and we only selected one focal child for data collection and analysis which likely oversimplifies the multiple family factors at play implications the findings of this study have implications for criminal justice system programs and policies that affect black fathers in jail and during reentry we recommend offering parenting programs in jail increasing family support during jail incarceration and reentry and facilitating contact with children during incarceration as corrections systems begin to recognize the importance of family factors during and following incarceration an increasing number of parenting programs have been offered in prison settings 91 such programs can reaffirm the identity of incarcerated parents and help them maintain and build positive relationships with family members from a distance 89 some of the more rigorously implemented and evaluated programs have even shown effects on recidivism for example researchers found that incarcerated parents who participated in the parenting inside out parenting program had 41 fewer arrests within a year after release than participants in the control group 92 it is also important to go beyond indicators of recidivism and examine other factors that reflect reintegration into families and society following incarceration 4 despite these encouraging findings and the importance of understanding parental identity during jail stays few familybased programs are offered to parents in jails 45 as most incarceration in the united states occurs in jails and few services are available there are numerous opportunities to increase provision of familybased jail programs and jail reentry support services it is most helpful if the services are genderresponsive for both incarcerated men and women culturally appropriate and are integrated with other services that attend to mental and physical health substance use employment and housing issues integrating the services can help support multiple parental identities such as parent as nurturer and parent as provider similar to parents returning from prison parents reentering from jail often rely on family support to reintegrate into the community 45 and children often provide motivation for incarcerated fathers to succeed during reentry 26 strengthening family relations including fatherchild fathercaregiver and fathergrandparent relationships during incarceration may help adjustment and parental identity during incarceration and with transitions into the community which can impact recidivism rates reintegration success and wellbeing of individuals families and communities offering opportunities for supported parentchild contact during incarceration including lowcost or free phone calls and inperson or remote visits can bolster parental identity during incarceration and increase resilience in both parents and children 93 childfriendly visitsinvolving preparation for children and families childfocused activities ample physical contact opportunities to share snacks and meals freedom of movement modified security procedures and contact between visitshelp children and their incarcerated parents meaningfully engage with each other and often lead to positive child outcomes in the context of parental incarceration and improved mental health in incarcerated parents 94 inhome remote visiting can also be a positive way for children and incarcerated parents to connect with each other especially when inperson visits are not available or when families do not want to bring children into a carceral environment such as when a parent or caregiver is exercising their role as protector justice professionals have identified the need for intensive cognitive behavioral case management to address risk need and responsivity factors such as homelessness substance abuse and the lack of medical insurance for those released from prison to reduce recidivism 96 scholars suggest that clinicians engage in personal reflection on their views about incarceration and incarcerated individuals recognize the important cultural context of kinship networks explore conditions of selfworth and above all appreciate the impact of systemic inequality and forprofit corrections on the lives of racially marginalized individuals 97 conclusions overall the results of this study highlight the resilience of black fathers and their families despite the risks associated with incarceration including the importance of family support during incarceration children as motivation for not reoffending how the justice system weighs the bidirectional influences of fathers and families supplementary materials the following supporting information can be downloaded at table s1 nature of fathers offenses author contributions conceptualization jpt and at methodology jpt and at formal analysis jpt and jcw investigation at jcw jpt and djpj data curation jcw and jpt writingoriginal draft preparation at jcw jpt and djpj writingreview and editing at jpt and djpj project administration jpt funding acquisition jpt all authors have read and agreed to the published version of the manuscript informed consent statement informed consent was obtained from all subjects involved in the study data availability statement the deidentified data set is available from the corresponding author upon request

we report on the findings of a mixed methods longitudinal study of 84 african american fathers of young children who were enrolled into the study during the fathers jail stay participants were assessed using interviews selfreport measures and administrative records on frequency of fatherchild contact fathercaregiver relationship quality family support paternal preincarceration employment fathers plans to live with the child upon reentry history of substance abuse and new convictions one year following release from jail qualitative analysis revealed three primary identities of fathers during incarceration father as nurturer father as protector and father as provider qualitative analysis of interview data detailed the ways in which the context of incarceration and the presence of the criminal justice system interacts with these identities to impact family structure parentchild visits plans for release and motivation for desistance quantitative analysis indicated heterogeneity among fathers with links between parentchild contact and desistance conditional on fathers plans for coresidence with children as well as family support and relationship quality taken together the findings highlight the strengths of african american fathers and their families despite the risks associated with incarceration including the importance of family support and children as motivation for desistance the results have implications for how the justice system weighs the bidirectional influences of fathers and families

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introduction the number of older adults people is increasing in all countries of the world and it will reach one sixth of the worlds population by 2030 1 the department of statistics expects that in 2030 the older adults in jordan will constitute 7 7 of the total population of the kingdom 2 it is known that the older adults have characteristics and features that distinguish them from other age groups studies have confirmed that if the older adults could live in a supportive environment their ability to do things that interest them would not differ much from the ability of younger people on the other hand if the older adults spent their days suffering from a decline in their physical and mental capabilities the consequences would be more severe for them and for their society it has become known that the possibility of depression mental illness and sense of isolation among older adults who are connected to the world through the internet is less than their peers who do not do so social media platforms have become a haven for this group for social integration which they usually lack 3 this is because social networks have become an important ally for the elderly 4 therefore it is important to know how older adults use social media platforms and the potential benefits and risks of this use problem statement the jordanian older adults constitute of the total population in jordan and this percentage is subject to increase during the upcoming years 2 and it is recognized that dealing with modern communication technology has become urgent in our time at the same time studies show that despite of the increase in the rates of the older adults use of social media platforms these rates are still less than the rates of use in younger age groups 5 older adults need to deal with these platforms in order to avoid the feeling of social isolation that usually accompanies them if the older adults could live in a supportive environment their effectiveness would not differ much from the effectiveness of the younger people on the other hand if the older adults spent their lives suffering from a decline in their physical and mental capabilities the consequences for them and for the society would be very severe 6 so it is important to know how the older adults in jordan use social networking platforms the questions the main question is how jordanian older adults use social media platforms facebook whatsapp twitter and tiktok relatively the study will answer the following questions 1 what is the ratio of the older adults who use social media platforms ©2023 nsp natural sciences publishing cor 2 what are the older adults usage habits of social media platforms 3 what is the level of the older adults confidence in social media platforms 4 what are the gratifications of social media platforms achieved for the older adults 5 what are the most attractive topics for the older adults on social media 6 what are the most social media platforms preferred by the older adults the aims the article aims to explore the ratio of the older adults who use social networking and to identify the habits of the older adults use of social media platforms it will also show the gratifications achieved by the social media platforms for the older adults moreover it will discover the most attractive topics for the older adults on social networking sites and identify which social networks are preferred by the older adults the importance the older adults are one of the important groups of the society that faces many difficulties especially in their feeling of isolation and their communication with others and it is noteworthy that the involvement of this group in dealing with modern technology and social media platforms can treat or reduce these difficulties consequently this article is based on identifying the usage of the most widespread social media platforms by the older adults in jordan furthermore it provides information that the jordanian and arab library missed and it can also provide accurate information to decision makers to benefit from it terminology older adults the older adults means the people who have reached years or more which is the scale set by world health organization 1 social media platforms it is a group of social networks created for communication and publishing the data and information by individuals or organizations with links as a result of social interaction represented by a dynamic structure or form of a social group that arises to expand and activate professional relationships or friendship relationships as it is called on social media 7 literature review the uses and gratifications theory the uses and gratifications theory are a theoretical background to the present article the theory was introduced in 1959 by katz 8 the theory focused on the transmission of the most prominent element in mass communication from the message to the audience thus negating the prevalent concept of almost absolute recognition of the power of the media 9 the uses and gratification theory offers a special insight into understanding the impact of individual and social differences on behavior related to media exposure the theory states that the audience chooses the medium and the contents that the audience wants to pursue based on several complex and interrelated factors including cultural backgrounds personality lifestyle age gender income education economic level and others 10 thus the old concept that the audience is merely a passive recipient has been transcended 11 since that transformation the concept of a positive audience has emerged which chooses the media material that it believes satisfies its needs from here the media has a new function represented in identifying the trends and tastes of the recipients and creating the media message that is commensurate with the needs of the recipient audience on the one hand and the desires and capabilities of the media person on the other hand 12 interactive media the internet and social platforms have enhanced the possibilities of audience participation with ease and ease and the advent of the computer has strengthened the conformity of the theory that began with newspapers radio and television to be compatible with the internet now 13 the theory helps explain the many and varied reasons why audiences use social media platforms 14 the theory of uses and gratifications also provided a new criterion for inferring the prevailing cultural level in a society by identifying the publics uses of the media and not through the content of the media message that these means perform 15 this theory refers to the possibility of achieving varying gratifications among groups of the audience in the same media content 16 for others it depends on the type of gratifications that exposure achieves for the recipient ©2023 nsp natural sciences publishing cor accordingly the theory of uses and gratifications differed from previous theories in that it dealt with the characteristics of the audience that is exposed to the media in terms of characteristics and motives away from the argument of habituation and acceptance of what is presented to it 17 previous studies by reviewing previous studies related to the older adults usage of social media platforms the scarcity of jordanian studies directly related to the subject of the study is clear abdel aziz 18 aimed to monitor the motives of the older adults use of social media and the gratifications achieved as a result of this usage as well as observing the extent of their confidence in it in addition to identifying the most social media platforms that the older adults use by conducting a field survey on an intentional sample based on egyptian older adults sixty year old moreover the study showed that there is a high usage of social media by older adults facebook came first followed by whatsapp youtube twitter google plus then instagram while other sites came at low levels the results also concluded that the high level of the utilitarians motives is associated with acquisition the results also indicated that the basic motives for follow up are learning knowledge acquisition and education while ritual motives and spending free time were not within the interests of the older adults wiwatkunupakarn 19 examined the relation between sns use and social isolation loneliness and depression in older adults an electronic online literature search was conducted up to june 2020 using three databases to look for references and find potential studies inclusion criteria were based on his three main principles a study population of adults over the age of 60 investigating sns use and reporting consequent depression loneliness or social isolation wiwatkunupakarn used 15 articles 10 observational studies and 5 experimental studies there was some evidence in observational studies that sns usage was associated with lower levels of depression and loneliness however a minimal number of experimental studies have yielded similar results regarding social isolation no studies have found a significant association between sns usage and lower levels of social isolation this review found minimal evidence particularly from experimental studies to support an association between sns usage and depression loneliness and social isolation in older adults through a critical evaluation of about 26 recent studies between 2019 2021 related to the older adults in the united states of america and europe cotten et al 5 highlighted the relationship between the use of social media platforms and luxury in the older adults in addition to the effect of using these platforms on the daily situations of the older adults the results also indicated that despite the increasing use of social media platforms their use is less widespread by the older adults moreover the results showed that the use of these platforms could help the older adults maintain social ties the study recommended the need to conduct research that uses longitudinal designs that include accurate standards for the use of social media platforms so that we can determine when the use of social platforms is useful and when it is not by using the comparative approach moftah et al 20 explained the necessary procedures to activate virtual learning as a means of digital literacy among the older adults in egypt and britain interpreting them in light of the influencing cultural forces and factors and identifying similarities and differences between egypt and britain in the role of virtual learning in digital literacy for the older adults they concluded that it is necessary to seek the help of experts in curricula and communication technology in creating many virtual educational platforms these platforms must be characterized by ease of design and simplicity of use so that the older adults can surf through them easily the research also recommended creating web pages or pages on social media platforms such as facebook and youtube being the most used in egypt to spread technological awareness among the older adults the study suggested the use of various enhancement tools and methods to attract the older adults towards using the modern technology of communication fu xie 6 revealed the impact of using the internet on the physical and mental health of the older adults whether the effect is positive or negative and homogeneous or heterogeneous the study relied on data from the 2017 chinese social survey to analyze the effects of using social media platforms on the physical and mental health of the older adults the results showed that there was a statistically significant positive correlation between the use of social media platforms and the health of the older adults the results revealed that the effect of using social media platforms on the mental health of older adults is more important than its effect on their physical health the researchers recommended the necessity of urging the older adults to use the internet while being careful of its disadvantages at the ussher institute for lifelong learning breck et al 21 revealed the effect of reverse orientation in addressing the challenge of social isolation in social work within an intergenerational program that serves the older adults the program included older adults and young mentors who completed three sessions of the program data were collected from the records of young mentors for each session and then through open questions about subsequent surveys that were collected from the older adults and young mentors findings on three themes related to social communication showed an increased sense of selfefficacy for older adults as they build confidence in technological use and for young people as they develop leadership skills through mentoring breaking down agerelated stereotypes and intergenerational ©2023 nsp natural sciences publishing cor engagement and communication the results also showed that reverse orientation could be used in different settings to reduce the social isolation of the older adults by developing intergenerational connections and increasing their use of technology through critical analysis fahim 22 traced studies that dealt with the older adults relationship with modern technological means of communication he revealed that the scientific heritage was interested in studying the relationship of the older adults with communication technology the functional use of communication technology as well as the factors and variables affecting the older adults use of this technology the scientific heritage also studied the obstacles and difficulties of the older adults use of communication technology in addition to the effects of their interaction with communication technology these effects varied between mental or cognitive physical and psychosocial effects fahim concluded that the psychological social demographic and health characteristics of the older adults can help predict who is most likely to use communication technologies he also indicated that foreign studies dealt with the nature of the interaction of the older adults with these means as the aspects studied varied however it appeared that this type of study was far from the research interest in arabic studies vosner et al 23 identified the factors that influence the use of social networks by active older internet users in addition to revealing their degree of ict use by conducting a field survey on a sample of older adults active internet users from the republic of slovenia aged between 45 and 74 years it was shown that the female participants were more familiar with the term online social network and were more frequent users compared to the male participants the results also indicated that age gender and education were the most important factors influencing the use of social networks by older active internet users many previous studies indicated a decrease in the percentage of older adults use of the internet such as cotten et al 5 moftah et al 20 and breck et al 21 in addition to the studies emphasizing the need to encourage the older adults to deal with the internet and make it easier for them by teaching them the necessary skills to deal with modern technology such as moftah et al 20 and breck et al 21 some studies focused on the motivations of the older adults to use social networking sites such as abdulaziz 18 and fu xie 6 on the other hand the studies correlated the issue of social isolation and depression among the older adults and their use of social media platforms most studies agreed that the involvement of the older adults in dealing with these platforms avoids or reduces negative feelings in the elderly and reported that the use of social media platforms was associated with lower levels of depression scores and loneliness methodology method the descriptive approach was adopted as it is appropriate to achieve the objective of the current study the descriptive approach is one of the most important approaches used in social studies population and sample the community consists of all adults in jordan whose age has reached or exceeded years the research sample consisted of older adults divided equally data collection the survey questionnaire was used for all the data and to identify the features of the older adults usage of the most popular social media platforms in jordanian society which are the questionnaire was distributed to the sample members directly by meeting them the researcher got all the answers 3 data shows that of the older adults always use social media platforms which represents of the total number of elderly people the percentage of the older adults who sometimes use social media platforms is of the users of the total sample and rarely of the users and of the total sample the table also shows that of the older adults use social media platforms for an hour or less which represents of the total sample as for the those who spend 23 hours their percentage is which represents of the total older adults those who spend 34 hours per day represent of the users and of the total sample the percentage of those who spend more than 4 hours per day is of users of all older adults users and nonusers of social media platforms table shows that of the older adults who use social media platforms have highly confidence in these platforms and they constitute of the total sample that includes users and nonusers the percentage of those who trust in the moderately level is of the users and of the total sample the percentage of those who trust these platforms is low of users and of all elderly users and nonusers of social media platforms results the elderly use of social networking sites the older adults use habits of social media platforms the level of the older adults confidence in social media platforms the gratifications of social media platforms achieved for the elderly discussion the older adults users it turned out that the older adults who use social media platforms represent while the percentage of those who do not use the platforms is this means that a quarter of the older adults do not deal with social media platforms in jordan this percentage is not low and needs to be studied when returning to the positive audience concept in the uses and gratifications theory we must pay attention to the fact that social media platforms are used by the internet the internet differs from other media as its use requires proficiency in the recipients special skills listening to the radio or watching television does not require more than pressing a button to open it and exposure to its programmes this matter does not apply to the internet using the internet requires a digital competence that the older adults may not have to be able to use technology this is confirmed by breck et al and moftah et al 20 21 and described the inability to deal with the internet as digital illiteracy which is common among the older adults this brings us back to the uses and gratifications theory when it provided a new criterion for inferring the prevailing cultural level in a society by identifying the publics uses of the media according to this criterion the presence of nearly a quarter of the older adults who are far from dealing with the internet indicates that the cultural level related to modern technology is declining or nonexistent among a large proportion of the older adults in jordanian society on the other hand this study is distinguished from previous studies in that its sample consisted of all older adults users and nonusers of social media platforms which enabled it to know the percentages of users and nonusers it must be noted that foreign studies did not focus on the importance of abilities to deal with digital technology except for breck 21 in contrast to most arab studies despite their scarcity this may be because the world preceded our region by introducing technology and the internet to it and this precedent made the older adults there more able to deal with modern technology because they dealt with it while they were young unlike the older adults in third world countries the habits of the older adults users it turned out that of the older adults always use social media platforms meaning that nearly ninetenths of the users of these platforms always use them and this is a high percentage which is related to the result of the first question the older adults who are good at dealing with digital technology use it permanently and this is an indication that the use of social media platforms satisfies their needs to a large extent according to the theory of uses and needs which confirms that the audience chooses the media material that it believes satisfies its needs as for the users who sometimes use social media platforms their percentage is of the users and this is a small percentage the least of them was the percentage of those who rarely use these platforms as it reached of the users this is a clear indication that the older adults who can deal with social media platforms continue to use them the older adults users confidence older adults who trust social media platforms at the middle level represent or nearly half of the sample this is a logical percentage because those who produce the contents of these platforms are ordinary people or specialists and these contents vary between messages that carry true and false information and those that carry objective and biased opinions therefore it is natural to trust what is published on middle platforms as for those who highly trust social media platforms their percentage reached of the older adults users meaning that the percentage of elderly people older adults who trust social platforms is only about onetenth of the users compared to who have low trust in these platforms this is normal because the older adults are known to be cautious and apprehensive so their tendency to doubt is greater as the life experiences that they have gone through during their lives make them more cautious the users gratifications of the older adults who use social media platforms believe that these platforms highly increase their information and their cognitive content on the other hand of them consider that these platforms highly improve their social relations highly and of them consider that these platforms positively affect their psyche highly and that the rise of these percentages indicates that the older adults deal with social networking sites in a way that achieves a high level of gratification for them based on the theory of uses and gratifications the ability of social media platforms to allow interaction in various forms with the public as well as the possibilities of the audiences participation in it easily explains the great gratifications achieved by the older adults as a result of their use of these platforms this result is consistent with the findings of abdelaziz 18 which concluded that there is a high percentage of utilitarian motives associated with acquiring information learning about different points of view and following up on older adults developments it also agrees with cotten et al 5 who found out that the use of social media platforms can help the older adults maintain social links but they also found that the relationships between the use of social media and the wellbeing of the older adults are not well understood therefore they called for more studies to verify this matter cotton et al agreed with breck et al 21 who concluded that the older adults use of social media platforms increased the elderlys their sense of selfefficacy while they built confidence in technological use the older adults use of social media platforms collapsed the stereotypes associated with age and the resulting feeling of disability and helped them achieve the possibility of participation and intergenerational communication the current results showed that of the users believed that the use of social media platforms increased their information and knowledge content moderately while of the users believed that the use of social media platforms improved their social relations moderately and of users who use social media platforms positively believed that it affected their psyche moderately only consider that they seldom obtain information and that platforms rarely contribute to increasing their knowledge content consider that these platforms have improved their social relations low and that the positive impact on their psyche as a result of their use of these platforms was low these low percentages indicate that the percentage of gratification achieved by the older adults as a result of their use of social media platforms is the predominant achievement the users preferred topics the results showed that the most attractive topics for the older adults on social media platforms were religious topics indicating the nature of jordanian society whose members tend to be religious especially the elderly social issues came second because the most difficult thing facing the older adults is the feeling of social isolation and therefore their need for social communication makes them accept more social issues it seems that if the jordanian society was not a religious society social issues would have come first political topics ranked third and this fits the situation in the arab countries in terms of conflicts and fluctuations and their impact on peoples daily lives as for entertainment topics they attracted of the older adults who use social networking sites this is a reasonable result as one of the most difficult issues facing the older adults is feeling bored and it is natural for those who feel bored to turn to entertainment but it is not expected that health issues are the last concern of the older adults although it is expected that the older adults usually face health problems the reason may be due to the family cohesion that exists in jordanian society as the sick older adults receive great care from their families and relatives which may make them uninterested in following up on health issues because they do not need them as long as there is someone who plays this role in general the differences between important topics for the older adults who use social media platforms are not large this is consistent with the proposition of the uses and gratifications theory that focused on the characteristics and motives of the audience who is exposed to the media away from the argument of getting used to and accepting what is presented to them the theory indicates the possibility of achieving gratifications varying segments of the audience in the same media content and this is what happens when the older adults enter the social media platforms thus the content may constitute educational material for some entertainment material for others or acquaintance and new friendships for others as it depends on the type of gratification that exposure achieves for the older adults the most platforms preferred by the older adults facebook is the first social platform to attract the older adults then whatsapp tiktok and finally twitter this result confirms what abdel aziz 18 concluded which revealed that the preferences of the older adult users of social media platforms in egypt tended to facebook first then whatsapp youtube and finally twitter it seems that the facebook platform provides the greatest satisfaction for the older adults in addition to the ease of dealing with facebook the diversity of its contents and its popularity the low preference rate for the twitter platform among the older adults is attributed to the fact that many consider it an elitist platform which is not as popular among people as facebook is in addition it restricts the number of words in its messages which may disturb the older adults more than other segments of society the most common thing that the older adults suffer from in the real world is their inability to reveal and talk at length with those around them who are preoccupied with the burdens of their daily lives older adults go to the virtual world to satisfy their need for communication and it is clear that facebook satisfies this need to a much greater extent than twitter conclusion the article explored the uses of social platforms by the older adults in jordan it revealed that most of the older adults use facebook more than other social media platforms this social platform provided them with knowledge and improved their social relations furthermore it had a positive impact on their psychological condition the preferred content by the older adults was the religious content followed by social topics ©2023 nsp natural sciences publishing cor recommendations the author recommends training the older adults on the skills of dealing with communication tools and technology as much as possible and removing the barrier of fear or embarrassment from using them it is important to use various reinforcement tools and methods to attract the older adults towards the use of communication tools and technology to reduce their sense of social isolation moreover it is necessary to conduct more studies related to the use of social media platforms by the older adults in the arab region to reach accurate conclusions about the various related aspects 5 data shows that of the older adults who use social media platforms believed that these platforms enriched their information and cognitive content highly while of the users believed that using social media platforms increased their information and cognitive content moderately while considered that they got a little amount of information and platforms lowly contributed to increasing their knowledge content the table also shows that of the older adults who use social media platforms consider that these platforms improve their social relations highly while of the users believe that using social media platforms improves their social relations moderately while considers that these platforms improve their social relationships lowly furthermore the data shows that of the older adults who use social media platforms consider that these platforms positively affect their psyche highly while of the users believe that the use of social media platforms positively affects their psyche moderately of the users stated that the positive impact on their psyche as a result of their use of these platforms was considered lowly shows that the most attractive topics for the older adults on social media platforms are religious topics then social topics followed by political topics then entertainment topics and finally health topics 83 shows that facebook is the most attractive social platform for the older adults with a rate of then whatsapp followed by tiktok and finally twitter 48 the most attractive topics for the older adults on social media the most social media platforms preferred by the older adults conflict of interest the author certifies that she has no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript

the article aims to identify the uses of social networking platforms by the older adults in jordan their exposure habits the gratifications the topics that most attract them and the platforms they prefer the descriptive survey method that had been adopted was using a questionnaire distributed to 400 older people in jordan the results concluded that 78 of the older adults use social media platforms first facebook then whatsapp tiktok and twitter and 498 of them trust them it also indicated that 747 of them believed that these platforms increased their acquaintances while 532 considered them to have improved their social relations 516 of them considered that social media platforms had a positive impact on their psychological condition religious topics were the most preferred for them followed by social topics politics then entertainment and health topics came last the author recommended teaching the older adults more skills of dealing with the internet encouraging them to use social networking platforms and conducting more studies related to the uses of social networking platforms by the older adults in the arab region

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introduction pressure ulcers are a serious secondary condition that can occur after spinal cord injury and have been linked with longterm mortality pressure ulcers are one of the most common complications occurring among people with sci despite extensive literature and research on prevention and treatment their prevalence is still high several studies have found a relationship between raceethnicity and prus in the general population african americans were found at higher risk of mortality from prus than whites although fuhrer and associates found no differences in the prevalence of prus between african americans and whites they did find that african americans were more likely to have severe prus than whites additional studies have found a similar relationship between race and pru severity in the sci population saladin and associates found that american indians had greater odds of prus within the past year than hispanics and that african americans and american indians had greater odds of a current pru than hispanics whites were included in the study but were not significantly different from hispanics one study using a relatively small sample size of veterans with sci found that race was the strongest predictor of recurrent prus where african americans were significantly more likely to have recurrent prus than whites additionally a study using the sci model systems data found that being african american was a risk factor for stage ii or higher prus a major limitation of the previous studies is that although all 3 studies in some way examined education in relation to pru none took into account income as a possible mediator in the relationship between race and prus it is important to consider race and socioeconomic status because in the us ses race and health have historically been linked to one another studies have shown that low ses including low income occupation type and education is consistently related to reduced access to quality health care further examination of the problematic health care issues shows that the populations most often affected are minority groups african americans tend to have less education and lower income and experience poverty at all ages as opposed to whites this can lead to diminished access to health care which contributes to the gap in equality between different racial groups and their health outcomes longitudinal studies have shown that low education typically predicts a decline in health although literature suggests that education and health care access facilitate better outcomes after an injury these resources are not always obtainable for people with sci purpose and hypotheses the objective of the current research is to identify risk factors associated with prus after sci by examining race and ses we hypothesize that african americans will have a greater risk for prus than whites but that this relationship will be mediated by 2 ses indicators a mediational model occurs when an independent variable is associated with an outcome but the relationship disappears after accounting for a mediating variable methods after receiving approval from the institutional review board participants for a mailin survey were identified through 3 different sources of records at a large specialty hospital in the southeastern us sci model systems database model systems registry and outpatient directory there were 3 inclusion criteria traumatic sci age 18 years or older at assessment and minimum of 1 year after injury of 2480 potential participants meeting these criteria 1549 returned their survey because nearly all participants were white or african american there were insufficient numbers of other racialethnic groups for the analysis therefore the sample was reduced to 1466 after eliminating all nonwhite and nonafrican american participants data collection procedures five weeks before receiving an initial packet of study materials participants were sent preliminary letters that described the intended research and the method by which they would receive the materials the initial packet included a letter that described the study and served as implied consent as well as the survey to be completed and mailed in if the initial packet was not returned a second mailing was set in place for all nonrespondents if the participant did not respond a phone call was made to engage in active conversation with the potential participant a third mailing was then used for those participants who had misplaced or accidently discarded the materials but consented by phone to receive another packet measures measurements were taken using a mail survey tool we used a subset of measures from a larger study of protective and risk factors associated with the onset of multiple types of adverse health outcomes and secondary conditions among a large sample of individuals with sci specifically for this study income education race and prus were examined our outcome in this study was prus and several items were used to assess this outcome first participants were asked all totaled how many different open pressure sores have you had in the past year this was dichotomized as none or one or more additionally participants were asked do you have at least one open sore right now and since your injury how many surgeries have you had to repair pressure sores the number of surgeries was dichotomized into none or one or more we only asked participants to report open prus because it might be difficult for some participants to recognize a less severe pru especially people with pigmented skin therefore all results in this study are referring to open prus this measurement has been used in previous studies of people with sci biographic and injury characteristics were assessed injury severity was categorized as c1c4 nonambulatory c5c8 nonambulatory noncervical nonambulatory and ambulatory regardless of level race was categorized as white or african american there were 2 indicators of ses education and income the participant was asked the exact number of years of education he or she had completed although we did not explicitly differentiate between fulland parttime education years of education were anchored with educational milestones participants were asked their annual household income which was recoded into 3 categories 25000 25000 74999 and 75000 analysis preliminary analyses were used to summarize the participant sample in terms of prus and biographic injury educational and ses characteristics during the preliminary analyses the x 2 statistic was used to evaluate the statistical significance of categoric variables whereas the t test was used for continuous variables the results of these analyses were used in model building for the model building we used multivariable logistic regression with each of 3 outcomes prus in the past year current pru and ever having had surgery for a pru all variables were included in the analyses except for age in the model for pru in the past year and the pru surgery model and age at injury in the current pru model because these variables were not statistically significant during preliminary analyses for each model we used a 2stage hierarchic modelbuilding strategy in the first stage of each model race was entered with the other biographic and injury characteristics in the second stage ses variables were added to the previous model we used p 005 as the cutoff for statistical significance in the final model finally interactions between race and income and education were tested in each model hosmerlemeshow and global x 2 tests were used to assess goodness of fit of the model the cstatistic measuring area under the receiver operating characteristic curve was used to assess discriminatory ability odds ratios with 95 cis are reported results descriptive of 1466 participants meeting the selection criteria 230 were african american and 729 were men average age at injury was 325 years with the average years since injury being 126 just less than 28 were able to ambulate the remaining nonambulatory participants were nearly equally divided between cervical and noncervical only 267 completed a bachelors degree or higher 325 had completed some education beyond high school 262 reported a high school certificate and 147 did not obtain a high school certificate household income 75000 was reported by 219 of participants and an income 25000 was reported by 406 thirtynine percent of the participants reported having a pru in the past year and 204 reported having a current pru additionally 234 had at least one surgery to repair a pru since his or her sci because we were testing mediational models we first assessed the relationship of the mediators with race both mediators were significantly associated with race income x 2 5 11733 p 00001 education x 2 5 7643 p 00001 pressure ulcer in past year calculation of the crude or indicated that neither race nor education were significantly associated with having at least one pru in the past year however household income was significantly associated because people with higher household income were less likely to have prus in the past year all other variables were significant with the exception of age at survey and thus were included in the final model after controlling for other variables in the model people with 25000 in household income per year were 258 times as likely to have a pru in the past year than those who made 75000 per year similarly people who make 25000 to 74999 per year were also more likely to have had at least one pru in the past year people who were nonambulatory were more likely to have prus in the past year than those who were ambulatory lastly the more years that had passed since injury the more likely the participants were to have prus in the past year current pressure ulcer race education and household income were all significantly related to having a current pru in the univariate analysis race became nonsignificant when education and income were added to the base model education retained a significant relationship with having a current pru because individuals with less than a high school certificate were 206 times more likely to have a current pru than those with a bachelors degree or higher additionally people whose household income was 25000 per year were 197 times as likely to have a current pru than those with 75000 of the other predictors people of older age were more likely to have a current pru pressure ulcer surgery since sci onset in the univariate analysis race was significant with african americans being more likely to have ever had a surgery for a pru than whites education and household income were also significant with those with less education and those with less income being more likely to have had a surgery for a pru since injury race remained significant in the base model while controlling for biographic and injury characteristics but was nonsignificant in the mediating model that included education and household income in that model education also was nonsignificant but low income was associated with increased odds of having had a surgery for a pru since injury similar to the previous model having more years since injury was associated with surgery for a pru as was being nonambulatory discussion our findings generally confirm previous research that identified a significantly higher risk of pru as a function of race although the findings were not unequivocal previously chen and associates found african americans to be at increased risk for stage ii or greater prus after controlling for education level and saladin and krause found racialethnic differences between african americans and hispanics and between american indians and hispanics also race was a significant predictor of 2 of 3 pru outcomes including a current pru and the history of at least one surgical intervention for people in each case african american participants were at greater risk than white participants we also tested mediational models for each outcome to identify whether 2 aspects of ses education and household income mediate any observed relationships between race and pru for mediation to be demonstrated there must be a significant relationship between the primary variable in this case race and each of the pru outcome measures because only 2 of 3 pru outcomes were significantly related to race mediation was only possible for a current pru and a history of surgical intervention for pru the second condition for mediation that the mediators were related to race was met in each of the 3 analyses the final and most important test of mediation is whether the initial relationship between the predictor and outcome is no longer significant after introduction of the mediators this was true in each instance therefore we can say that mediation occurred for 2 of the 3 outcomes it is interesting to note that years of education was not statistically significant after introduction of household income for having had surgery for a pru this study provides new information on the relationship between ses and prus through the inclusion of income as a predictor variable although one study out of canada found no relationship between income and prus it is difficult to draw conclusions from that study and apply them to the us population because the health care systems between the 2 countries are vastly different our results highlight the importance of income in relation to prus after sci and although it does provide a measurement of financial revenue income is also an important predictor because it is associated with health insurance and with access to health care these findings are not surprising given the importance of income in relation to mortality among people with sci however education was only related to having a current pru and race was not associated with any of the pru outcomes after controlling for other variables in the model these findings strongly suggest it is tangible income not education per se that is associated with risk of pru and the mediational relationship between race ses and pru the findings also suggest that the association of race with lower ses particularly lower income accounts for observed differences in pru after sci onset this is fully consistent with results of previous research indicating similar mediational effects of ses on the relationship between race and depressive symptoms among african american men interestingly in that study the mediational effects were complete only for men although partial mediation was observed for women income was also more important than education in that study limitations our study had 5 primary limitations first our data were selfreported and therefore could be subject to recall bias however most of our questions were limited in scope to the previous year to minimize recall bias second because our data were selfreported we were not able to assess the severity of reported prus but were limited to a more general assessment of the occurrence of an event although we limited our assessment to open prus it is possible that individuals reported all prus in their survey third we were not able to include races other than white and african american due to the limited number of participants from other races fourth these data were crosssectional so we were not able to assess the sequence of events for the variables measured lastly we were limited in our measurement of ses in that we included only education and household income future research future work is needed to gain a better understanding of the nature of the relationship between ses and prus future studies should expand on the measurement of ses and include more specific variables on access to health care and the use of health care services in relation to pru outcomes further research should include additional race and ethnic groups in the analysis future studies should assess the knowledge of prus and pru prevention among the different race and ses groups conclusion our findings have helped to clarify the relationships between race and ses with prus after sci specifically a lack of resources both financial and educational is

objective to identify risks factors associated with pressure ulcers pru after spinal cord injury sci by examining race and indicators of socioeconomic status measured by income and education we hypothesize african americans will have a greater risk for prus than whites but this relationship will be mediated by the 2 socioeconomic status indicators design cohort study setting a large rehabilitation hospital in the southeastern us participants 1466 white and african american adults at least 1year posttraumatic sci outcome measures a prus in the past year b current pru c surgery to repair a pru since injury results in preliminary analyses race was significantly associated with having a current pru and with having surgery to repair a pru since injury in multivariable analyses the relationships of pru with having a current pru and with having surgery to repair a pru were both mediated by income and education such that the relationships were no longer significant lower income was associated with increased odds of each pru outcome after controlling for other variables in the model education was associated with increased odds of having a current pru conclusion these findings help clarify the relationships between race and socioeconomic status with prus after sci specifically a lack of resources both financial and educational is associated with worse pru outcomes these results can be used by both providers and policy makers when considering prevention and intervention strategies for prus among people with sci

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the covid19 virus was first detected in december 2019 in wuhan china 1 on 11 march 2020 the world health organization declared the disease a global pandemic since its emergence there are more than 152 million confirmed global cases of the virus with the number of deaths exceeding 623 000 as of 23 july 2020 in the initial stages of the outbreak most cases of covid19 that were exported internationally had a history of prior travel to wuhan 2 despite its close geographic proximity with china and iran the first two cases of covid19 in pakistan were reported on 26 february 2020 3 to curb the spread of the virus provincial governments in pakistan initiated partial followed by complete lockdowns in their respective administrative territories these measures however were taken in phases with educational institutions across the country closing on 13 march 2020 in response to the pandemic 4 as of 23 july 2020 pakistan has over 260 000 confirmed cases of covid19 and approximately 5700 deaths 1 one year on pakistan has experienced four waves of the pandemic with a total number of 12 million cases and 26 000 deaths 5 exposure to a traumatic event such as a global health crisis is associated with an increased incidence of anxiety and depression 6 moreover the stigma and isolation associated with infectious diseases could generate anxiety 7 a study conducted on a sample of severe acute respiratory syndrome survivors in hong kong revealed increased levels of psychological distress and anxiety not only during the epidemic but also 1 year following the outbreak 8 another study concluded that sars had longterm psychiatric effects on survivors with posttraumatic stress disorder and depressive disorders being the most prevalent conditions recorded 9 moreover a survey conducted in the usa during the h1n1 pandemic with 7236 participants suggests an increase in the prevalence of anxiety 10 the covid19 pandemic is expected to affect womens health and increase their shortand longterm needs for livelihood support and health 11 a study conducted in the heavily affected areas around wuhan highlighted an increase of 7 in the prevalence of posttraumatic stress symptoms and women had significantly higher levels of ptss than men 12 during the sars epidemic people with higher levels of anxiety were frequently found to adopt precautionary behaviour 13 in keeping with this a study conducted in the uk found that women practiced precautionary behaviour such as hand washing and disinfecting surfaces more often than men 14 female responses to stress and trauma may be contributing factors toward anxiety studies also indicate that gendered responses to trauma contribute to the greater onset of depression and ptsd in women 15 evidence attributes this to women believing that worry is uncontrollable and may cause anxious thoughts 16 how young boys and girls are socialised into their gender roles has an impact on these perceptions a review discussed how mothers are more likely to converse about their emotional condition with their daughters compared with their sons 17 further young boys are conditioned to exercise problemsolving skills for managing their emotions girls are traditionally granted less autonomy this increases their dependency on others and reduces their capability to effectively cope with anxious thoughts 17 studies from the eastern mediterranean region further highlight this suggesting that this ineffective coping may result in a higher suicide rate among women 18 indeed in 2020 there were significantly higher female hospital admissions in malta compared with 2019 with increased presentations of selfharmsuicidal ideation 19 the reviewed literature suggests that women are more prone to anxiety and depression and that the mental health status of the population tends to deteriorate during large epidemics or pandemics the current crisis requires policies that facilitate largescale behaviour change science communication and strategies to cope with stress through psychological platforms 20 immediate risk assessment and quick action of vietnamese policy makers as well as the seamless coordination between government and citizens in implementing protective measures has resulted in low case numbers and zero deaths in the country this has been in conjunction with media appropriately promoting public awareness about how people can protect themselves and their communities 21 this study therefore aimed to identify gender differences in perceived risk anxiety levels and behavioural responses to covid19 this will help to develop genderresponsive policies to mitigate progression toward serious mental health conditions method study design this is a crosssectional study with the survey tool disseminated online the first case was reported on 26 february 2020 in pakistan the study was conducted between 1 may 2020 and 15 may 2020 during a governmentimposed lockdown ethical approval was obtained from the ethical review committee of the aga khan university pakistan study participants a convenience sampling strategy was used to recruit participants the questionnaire was launched for 2 weeks on the social media pages of a karachibased university hospital potential study participants were encouraged to share the link on their social media platforms people aged ≥18 years residing in pakistan for the past month with access to the internet and willingness to participate in the study were included participants who could not respond to the study tool in either english or urdu and those who reported having filled the questionnaire at least once before were excluded this was an online survey tool so no verbal or written consent could be taken in the traditional sense participants who met the abovestated eligibility criteria and consented to participate were able to further navigate the system respondents found ineligible or those not willing to consent were redirected to a thank you message and further access to the tool was halted by the google form a total of 1406 respondents completed the online questionnaire fifteen respondents preferred not to disclose their gender thus 1391 participants were included in this study data collection data was collected through an online selfadministered structured questionnaire developed on google forms respondents were inquired about their gender age level of education household income and city of permanent residence they were asked how likely it is that they or their families might be infected with covid19 if no preventive measures were taken further questions assessed how participants perceived the severity of the symptoms caused by covid19 their likelihood of survival if infected and their adoption of precautionary measures respondents also rated the reliability of various sources of covid19related information subsequently the psychological impact of covid19 on respondents jobs personal life sleep pattern and eating habits was assessed participants anxiety and depression levels were assessed by the validated hospital anxiety and depression scale this comprises 14 items scored on a fourpoint likert scale the lowest possible scores for anxiety and depression are 0 and the highest possible score is 15 for anxiety and 21 for depression the scale defines a normal score as ≥7 borderline abnormal score as 810 and abnormal score as ≤11 higher scores imply greater severity of anxiety or depression 22 data analysis data collected from respondents was stored in google spreadsheets then imported to microsoft excel 2016 and spss version 21 for windows data was cleaned coded and analysed with spss version 21 a descriptive analysis was performed results were tabulated as number for qualitative variables and mean for quantitative variables independent ttest mannwhitney utest or pearson χ 2 test was applied to assess the differences between womens and mens perception of susceptibility and severity toward covid19 anxiety depression the psychological impact of covid19 adoption of precautionary measures and reliability of information sources responses were classified as ʻmissing if respondents left the question blank and was excluded from the analysis dont know was an option in survey questions that required a response on a fivepoint likert scale wherein 4 and 5 were considered as agree and strongly agree respectively therefore if the respondents replied ʻdont know such responses were considered as a nonagreement on the scale this type of categorisation for likert scalebased responses is consistent with the literature 23 bivariate and multiple logistic regression analyses were performed to identify predictors of anxiety and depression initially a single predictor at a time was entered crude odds ratios and 95 confidence intervals were computed by bivariate analysis multivariate analysis with all predictors entered at the same time was completed to adjust for the effect of confounding and adjusted odds ratios and 95 confidence intervals were computed all statistical tests were twosided and a pvalue of ≤005 was considered statistically significant and indicated in results where appropriate exact pvalues are given where they are 005 results a total of 1391 participant responses were included in the analysis table 1 shows the sociodemographic characteristics of women and men which are comparable the majority of the respondents were aged between 25 and 34 years and possessed a bachelors degree or above about 29 of women and 17 of men preferred not to disclose their household income around a third of women and twofifths of men mentioned that their household income was below pkr 60 000 more women than men from karachi participated in the survey around threefourths of respondents perceived that they and their family might be infected with covid19 if no preventive measures were taken however significantly more women than men considered symptoms of covid19 as severe further 59 of women perceived themselves as likely to survive an infection compared with 73 of men women were also reported to have a higher hads anxiety score furthermore the hads depression score was high among women more women were found to be depressed compared with men with 58 of women and 54 of men scoring above the depression cutoff point around threefifths of the respondents mentioned that covid19 had affected their jobs about threefourths of the respondents also expressed concerns that the current pandemic is affecting their personal life about twofourths of the respondents believed that their sleeping pattern and eating habits have been disturbed because of covid19 significantly more men compared with women mentioned that they might startincrease cigarette consumption and might resort to the use of recreational drugs such as marijuana crystallised methamphetamines cocaine or opium products etc significant differences were identified between women and men in adopting several precautionary measures such as washing their hands with soapsanitiser frequently wearing masks covering nose and mouth when sneezing or coughing avoiding contacting people who have a fever or respiratory symptoms avoiding going out avoiding crowded areas refraining from going to a hospital or clinic avoiding going to work avoiding social events and avoiding domestic travel information about covid19 provided by the doctor was considered reliable by significantly more women than men most of the respondents thought that the information provided through official websites such as those run by the government was reliable significantly more men than women believed that the radio and family or friends were reliable sources for gaining information about covid19 furthermore television newspapers magazines social media such as facebook whatsapp and instagram and unofficial websites were considered as reliable information sources by more men than women table 6 demonstrates the predictors of anxiety gender age and household income had a significant positive association with anxiety women were nearly two times more likely to be anxious than men moreover respondents of a younger age were nearly two times more likely to have anxiety than respondents over 55 years of age respondents with a household income between pkr 60 000 and 120 000 were more likely to have anxiety than respondents with a household income of pkr 120 000 table 7 shows the predictors of depression only household income was found to have a significantly positive association with depression in multivariate analysis respondents having a household income of pkr 60 000120 000 were more likely to have anxiety compared with respondents who had a household income of pkr 120 000 discussion this study assessed how gender roles in pakistan can affect anxiety levels and behavioural responses among men and women during the covid19 pandemic both men and women were found to be anxious because of the covid19 pandemic however compared with men more women perceived the disease to be fatal and women were more likely to engage in preventive behaviour these results highlight a greater need to develop genderresponsive policies in the fight to contain covid19 overall fewer women than men responded to the questionnaire this may be because of the maledominated access to internet facilities in pakistan in pakistan cellular devices remain the most frequent means of accessing internet facilities and there is a gender gap of 38 in mobile phone ownership indeed several reports on internet penetration found that at least threefourths of internet and social media users in the country are male 24 there were also significant differences in respondents cities of permanent residence threefifths of all of the female participants and twofifths of the male participants were from karachi this was expected as the survey tool was disseminated over a karachibased university hospitals facebook page there are significant provincial disparities in access to internet facilities the fewest respondents were from balochistan further reflecting the provinces poor internet accessibility more male respondents were from smaller cities and towns throughout the country compared with a tenth of female respondents these differences can be attributable to fewer women having mobile phone ownership and social media usage in smaller townscities 24 although men and women considered themselves equally susceptible to a covid19 infection women were more likely to perceive the disease to be fatal and worry about their own and their familys healthcare apart from their professional role women serve as primary caregivers within their family 25 womens greater sensitivity toward familial roles and responsibilities was also reflected in a european study which noted that pregnant women had heightened stress levels regarding the health status of their older relatives children and unborn babies during covid19 26 similarly a comparison of covid19related content shared on twitter by men and women based in the usa found that women were more likely to tweet about family social distancing and healthcare whereas men were more likely to tweet about sports cancellations and politics 27 mens casual attitude can be explained by genderdisaggregated data on covid19 in pakistan which shows that threequarters of diagnosed cases and deaths were among men compared with a quarter among women 28 genderspecific patterns of smoking are implicated as a significant contributor to disease severity among men 29 it was also noted that men in our study had a higher likelihood to start smoking cigarettes and using recreational drugs during the pandemic compared with women it is therefore not surprising that excess mortality during the pandemic was higher among men complemented by comorbid noncommunicable diseases and a delay in seeking lifesaving care 3031 unequal share of household responsibilities and women staying home because of school closure lockdown and workfromhome orders may have resulted in women being more stressed housework is largely undocumented and unpaid 32 working mothers spend more hours engaged in household work and child care than their husbands one study conducted in the uk during the lockdown estimates that on average mothers spend 11 hours more per week on child care than fathers single mothers have less time to spend on child care than partnered mothers as they are singlehandedly forced to bear the brunt of the shifts in the job market 33 this additional housework could result in women permanently exiting from the labour market and add to their anxieties these developments are concerning and emphasise the urgent need to develop labour policies that protect women in the workforce despite being at lower risk of exposure to the disease and subsequently succumbing to it women in this study were more likely to practice hygiene measures and social distancing such as avoiding going to meat shopsmarkets going out and going to work the gallup survey conducted during various waves of the pandemic shows that pakistani women are more likely to stay at home as a preventive measure 34 one digital ethnographic study in pakistan suggests that one in four men reported having attended friday prayers during the early phase of the pandemic in 2020 35 although this finding might imply that men are considerably less interested in social distancing practices men constitute a majority of waged and salaried workers in cities and only a fifth of pakistani women are part of the labour force 36 these differences in employment could explain why men are less likely to conform to social distancing practices than women women were more likely to report that they avoid going to hospitals during the pandemic as a measure of social distancing it may be too soon to estimate the impact of covid19 on maternal and child health services but one study estimates that a modest decline of 10 in coverage of pregnancyrelated and newborn healthcare in lowand middleincome countries could result in an additional 17 million pregnant women and 26 million newborns in need of urgent medical care 37 research conducted during the 20132016 ebola outbreak in western africa shows how sexual and reproductive health was adversely affected by strains on healthcare systems which often resulted in interruptions of care and redirected resources 38 a similar reduction in access can be seen during the current pandemic clinics operated by marie stopes international which is the largest private provider of family planning services in pakistan reports that its activities have been reduced by up to 40 in pakistan as a result of the pandemic 39 furthermore some studies noted how the diversion of staff and funding from maternal neonatal and child health programmes to the front line of the covid19 response has also decreased the quality of services available to women 4041 although women refrained from accessing health facilities during the pandemic as a measure of social distancing they still considered doctors as the most reliable source of information on covid19 this is consistent with findings from the gallup survey in pakistan 34 hence social media awareness campaigns and telemedicine engaging doctors can target women who tend to be more socially isolated than men during the pandemic a study in karachi has also commented on the need to develop psychosocial support including essential assistance through online support groups awareness through television or social media and telemedicine for women 42 in this study women showed higher levels of anxiety and depression compared with men which suggests that they hold a greater psychiatric burden of the covid19 pandemic one study conducted in china established that 54 of respondents suffered some psychological effect from the outbreak 43 this chinese study found that women have suffered a greater psychological effect as a result of the pandemic compared with men and may be three times more anxious than their male counterparts similarly our findings corroborate with data from turkey where women had significantly higher scores of depression and anxiety 44 surely this indicates that women have a higher vulnerability for developing anxiety disorders this is a novel study accounting for differences in perceptions of men and women with regards to risk perceptions anxiety levels and behavioural responses to covid 19 however the study had some limitations the survey could only be accessed by the literate population in pakistan with access to internet so the generalisability of results needs to be viewed with caution moreover in this study most of the respondents were aged 35 years which may not accurately represent the views of the older population who are at greater risk of contracting covid19 nevertheless as the majority of the population in pakistan is 30 years of age the responses are likely to represent the perceptions of the literate general population in pakistan additionally the perceptions are related to the early phase of the pandemic and the trajectory of covid19related beliefs over time is yet to be determined however the anxieties around covid19 still prevail indeed the latest gallup survey in pakistan shows that approximately half of pakistanis in urban areas are worried if people around them do not wear masks in public 34 moreover a large survey assessing anxiety and depression symptoms in the usa found that women were equally anxious at the start of the pandemic as they were in august 2021 45 hence the recommendations of our study to develop genderresponsive psychosocial support strategies for women and provide additional support in their employment and child care are needed more than ever as we continue to battle with the pandemic in summary this study assessed the gender differences in risk perceptions preventive behaviour and anxiety levels during the early phase of covid19 the results highlight the need for genderresponsive policies in mitigating the health and economic impact of the covid19 pandemic the global economy has ground to a stop and respondents face severe economic uncertainty differences in type of work based on gender may result in men being unable to maintain social distancing furthermore it results in women being burdened with increasing housework which can affect their ability to engage in professional work and add to their stresses this indicates the urgent need to develop labour laws to protect the workforce particularly women furthermore the results indicate potential avenues of disseminating genderspecific health communication involving doctors in healthcare communication targeting women focusing on their need to avoid skipping hospital appointments might prove effective research is required to assess strategies of reducing the frequency of inperson maternal neonatal and child health appointments and the potential of telemedicine for all women to remain in contact with the health system as men are more likely to trust what they read on social media especially if it is shared by friends or family social media campaigns and radio programming may be effective in disseminating information and the latter could be an effective tool to diverse audiences 46 this health communication should include messages about mens higher risk of dying owing to covid19 a lack of noncommunicable disease management and smoking cessation most importantly based on the discussion policy measures must be taken to ensure the continued provision of quality healthcare to women differences in type of work based on gender may result in men being unable to maintain social distancing furthermore it results in women being burdened with increasing housework which can affect their ability to engage in professional work data availability data and materials from the study are in the custody of aga khan university anonymised data that support the findings of this study are available from the corresponding author fr upon reasonable request supplementary material supplementary material is available online at declaration of interest none

covid19 has rapidly spread across the world women may be especially vulnerable to depression and anxiety as a result of the pandemicthis study attempted to assess how gender affects risk perceptions anxiety levels and behavioural responses to the covid19 pandemic in pakistan to recommend genderresponsive health policiesa crosssectional online survey was conducted participants were asked to complete a sociodemographic data form the hospital anxiety and depression scale and questions on their risk perceptions preventive behaviour and information exposure multiple logistic regression analysis was used to assess the effects of factors such as age gender and household income on anxiety levelsof the 1391 respondents 478 were women and 913 were men women considered their chances of survival to be relatively lower than men 59 v 73 they were also more anxious 62 v 50 and more likely to adopt precautionary behaviour such as avoiding going to the hospital 78 v 71 not going to work 72 v 57 and using disinfectants 93 v 86 men were more likely to trust friends family and social media as reliable sources of covid19 information whereas women were more likely to trust doctorswomen experience a disproportionate burden of the psychological and social impact of the pandemic compared with men involving doctors in healthcare communication targeting women might prove effective social media and radio programmes may be effective in disseminating covid19related information to men

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background normal childbirth involves hard work to reach the happy end women endure hours of labor embracing feelings of pain and anxiety amidst hours of labor women are subjected to many routine medical procedures such as laboratory tests and obstetric examinations vaginal examination a frequent and core procedure during childbirth for making clinical decisions during childbirth ves give the provider the necessary information about cervical dilatation effacement fetal head position and status of membranes on admission these markers are necessary to decide if the woman is in labor during labor plotting these markers into a partogram will inform about progress of labor and constitute the basics for key decisions to be taken to manage labor such as accelerating labor or deciding on cesarean section if progress is not optimum over years ve continued to be plagued by a nature that implies negative feelings and experiences of women during childbirth women may report feelings of exposure 12 guilt shame and loneliness that increase their vulnerability studies on ve focus more on the procedure during gynecology situation 2 3 4 5 6 7 8 women preference regarding gender 910 providers practices 11 and ve training for medical students 12 13 14 15 16 few studies examined womens experiences of ve during childbirth 1718 or explored providers actual practices 1920 and none explored it in developing countries or the middle east region clinically ve is among the most accepted ways to assess progress during childbirth but its repetition at shorter intervals has no value 21 the nature of ve as a manual procedure depends on the providers perception gave the base to be criticized for limited accuracy 2223 and considered an imprecise measurement if conducted by different providers 24 the relationship between ves during labor and infections was documented 25 ve adds more pain discomfort and anxiety 17 triggers feelings of fear shame guilt exposure and powerlessness 6 thus negatively influences womens satisfaction 3 for these reasons the international clinical guidelines recommended a limited number of ves during labor 26 27 28 the sensitive nature of ve for both the provider and the woman necessitates greater concern especially in conservative cultures as per the arab cultural codes ve should not be performed for a never married women 29 as in addition to any vaginal intrusion is interpreted as a violation of womens virginity 30 and loss of family honor 31 in this study pregnant women are usually married during the assessment phase of this project midwives reported that they repeated ves during labor every less than one hour to 2 hours to follow up progress midwives added that women demanded ves because they believe that it helps to facilitate birth the documented frequency of ve was limited to 12 vaginal exams for the total duration of childbirth furthermore we documented that about half of women in an assessment phase reported being examined 522 times during childbirth 32 we reported a significant decrease in the frequency of unnecessary ves from an assessment to an intervention phase but it did not sustain 33 in this study we aim to explore the women feelings opinions knowledge and experiences of ve during childbirth methods study setting this is an exploratory study conducted in a general referral governmental hospital where about 4000 births occur each year in the occupied palestinian territory midwives and physicians are the main health care providers in the labordelivery ward 34 this hospital serves 75 communities and 6 refugee camps which include a total population of 301296 people 35 questionnaire we used a semistructured questionnaire through facetoface interviews with postpartum women we piloted the questionnaire on twelve postpartum women who were not included in the analysis the questionnaire consisted of three parts the womans sociodemographic information including parity and education their experience feelings and opinions about ves and their views of routine care during childbirth to explore about ve during normal childbirth we used the following questions respectively how did you feel during the internal check up during this childbirth what is your opinion about the internal check up during childbirth what do you know about internal check up in general how many times providers asked your permission for doing internal check up what did they tell you variables the who recommends that ve should be conducted at 4 hours interval and by the same provider if possible the mean total duration of labor in palestinian hospitals is relatively short 3336 based on these findings we considered that a frequency of more than 4 ves during normal childbirth to be mostly unnecessary and defined as a potentially high we defined the low frequency of ves during childbirth as 04 times we also defined a low number of providers as 12 providers and a high number as more than 2 providers table 1 illustrates definitions for feelings opinions knowledge and permission statement variables participants and data collection we targeted all postpartum women giving vaginal birth we selected a sample size of 200 postpartum women based on practicalities of time and cost as this was part of a pilot project focused on improving quality of care during normal childbirth in this hospital for convenience we collected this data on the same two days each week during which we were present in the hospital these two days were chosen by our field workers midwives ensuring that they are changing using different weekdays during the project in order to work with all midwives and under possible varied workloads we identified 200 eligible women out of a total 1489 women who delivered between the months of june to september 2008 a total of 176 postpartum women were interviewed five women refused to participate who were in rush to leave the hospital with their waiting family members and we missed to invite 19 postpartum women the missing women were women who left immediately after the discharge decision or against advice on the day of data collection all eligible cases would be identified we interviewed every other woman from the eligible cases women were interviewed in the second day after birth before discharge in the postpartum ward ensuring privacy as possible by using the curtains between beds and each took 1520 minutes to complete interviews were conducted in arabic a form was designed to track the number of postpartum women eligible interviewed refused to participate and missing each day of data collection we crosschecked not necessary refers to all termsstatements used by women to reflect that ve is unnecessary during childbirth as perceived by women such as no need not necessary dont like it not important for me when necessary refers to all termsstatements used by women to reflect that ve should be only done when indicated as perceived by women such as should be done but not too frequent should be done only when needed sometimes it is important and necessary and sometimes there is no need they decide if necessary or not knowledge variables correct responses all termsstatements used by a woman to reflect correct informationindication about ve and there was no incorrect informationindication in the womans response of this question these were the responses that were considered correct measures cervical dilation checks progress of labor checks fetal descent in the pelvis checks readiness for delivery checks amniotic membranes to rupture amniotic membranes checks real labor partially correct responses there was at least one correct informationindication in the womans response for this question no correct response all termsstatements used by a woman to reflect not correct informationindication about ve and there was no correct informationindication in the womans response of this question the followings were responses that were considered not correct makesaccelerates dilation measures amount of water assist in delivery checks inflammation or soreness in the uterus checks infection or vaginal diseases checks birth defects checks masses in the uterus after birth permission statement instruction statement refers to all statements that were reported by women to reflect an instruction for physical self preparation or support given by providers before or during the exam such as prepare yourself for an internal exam take off your clothes take a deep breath relax be strong information refers to all statements that were reported by women to reflect information given by providers to women about the ve or the findings of the exam such as i will check you up internally they told me how much i was dilated complaint refers to all statements that were reported by women to reflect a complaint fromrelated to the exam such as the door was open they refuse to cover me up they examined me directly without saying anything they never said anything i was screaming i was in pain sometimes they checked me several times close to each others yelled at me women request refers to all statements that were reported by women to clearly reflect that the woman requested to be examined vaginally such as i asked them to examine me the identified eligible women with the tracking form and the birth register to identify any missed women and none were detected other than the 19 women we continued to conduct interviews until we identified 200 postpartum women ethical consideration written and oral permissions were obtained before we started the project from the ministry of health the institute of community and public health and the hospital managers verbal informed consent was obtained from each woman before the interview confidentiality and voluntary basis of participation with rights to refuse were always ensured to women analysis results womens demographic and obstetric characteristics we interviewed 176 women of age varied from 16 to 42 with a mean of 263 years the majority of women were younger than 30 years the mean years of education was 104 around 68 of women had more than 9 years of education and the majority lived in rural areas 26 of women were primipara and 6 had more than 7 children midwives assisted 79 of women during childbirth women reports the mean number of ves during childbirth was 424 about 36 of women reported receiving a potentially high number of ve during their childbirth only 12 of women reported being examined by one provider and 41 of women reported being examined by a high number of providers during childbirth table 3 illustrates some of characteristics of the ve practice during normal childbirth as reported by women we tested the frequency of vaginal examination against selected indicators there was no significant difference between the proportion of women receiving low and high frequency of ves during childbirth and their age place of residence education level parity complications and the time of delivery the proportion of women who had potentially high frequency of ves during childbirth was significantly larger when the number of providers conducting ve was high and significantly larger when the woman is a primipara than multipara women womens feelings of ve women reported a total of 359 responses describing their feelings the contents of these responses were categorized into 4 categories the majority of women reported severe pain or pain and 68 reported discomfort only 5 of women reported embarrassment and 5 of women reported that ve reassured them during childbirth there was no significant i felt so tired when the provider inserted hisher fingers i felt as if i am going to die i do not like to be examined i felt severe pain and discomfort feeling pain during ve during childbirth was doubled when allergy to latex gloves existed one woman in this study complained of latex allergy she was given no choice but to tolerate a very painful ve on top of her labor pains the following case illustrates the details of these women feelings case 1 an example of disrespect r was 33 years old woman from a village near ramallah this was her 4 th baby this was her second time to give birth in this hospital rs husband was jobless she was assisted by a midwife into a normal vaginal birth she has uncomplicated pregnancy and childbirth r reported that she was examined twice during her labor by 2 different providers she reported that she has allergy to latex the material from which the examination gloves are usually made up of r reported her experience during vaginal examination and saidbefore the first vaginal examination i informed them that i have allergy to latex and usually i complain of scary irritation and burning sensation if latex gloves were used for vaginal examination i asked the staff to change the gloves and they answered that it is not possible i had severe pain burning and edema because of the vaginal examination with the latex gloves my edema down there increased with the second examination and during birth she added although vaginal examination is necessary during labor but it should not be done too frequent womens opinions of ve all women shared their opinions regarding ve during childbirth except three women who reported i dont know the majority 94 of women reported that ve during childbirth is beneficial 7 reported that it is not necessary and 6 reported that it should be done only when indicated some women reported insensitive approaches of providers especially physicians some reported insufficient means of privacy and no respect of dignity or their humanity during the exam 24 years old para 3 examined 8 times by 5 different providers reported ve is painful and discomforting but it can be easier if done by a midwife sometimes i felt that physicians are punishing us for being pregnant and they seem like fighting while doing the ve while conducting the ve physicians are more aggressive expose women a lot and in an insensitive way i believe that ve is necessary but should not be conducted too often because it is painful and not comfortable 24 years old para 2 examined 6 times by 4 different providers said i felt pain and discomfort especially if the examiner was a male physician i think ve is necessary to be done but there should be more privacy ie closing the door no curtains on the window womens knowledge of ve almost all women responded with at least one correct indication for ve and two women who answered by i dont know the women reported a total of 281 responses on knowledge regarding ve about 82 of women reported completely correct responses and only 3 of women answers were not correct about ve about 51 of the responses reported that ve is done to check dilation 16 to check fetal descent or progress and 8 to check readiness for delivery 4 for each to check or break the membranes and to check vaginal infections the majority of the incorrect responses reported that ve accelerates labor and delivery by increasing the dilation some other incorrect responses about ve were to check birth defects the amount of water masses after delivery many primipara women clearly indicated that they lack the information about ve before this experience for instance a primipara examined 4 times by 2 different providers reported only yesterday i knew about vaginal examination at the beginning i was afraid and i refused to be examined by a male physician because i feel embarrassed it was embarrassing with the physician 24 years old primipara examined 7 times by 3 different providers reported i knew nothing about ve yesterday was the first time i heard about it feels so embarrassing very discomforting and i do not like to be examined at all permission statement during ve all women reported statements used by their providers before ve a total of 242 responses we categorized these responses into four main categories these include statements to instruct women for physical preparation inform about the exam complain about the exam and only 3 of the responses indicated that women requested the ve about 77 of women reported that providers gave them instructions before the ve of these statements the most frequent statement was prepare yourself for an internal exam few women reported being instructed by providers for ways to cope with the exam such as relax or take a deep breath of all women only 28 reported that providers gave them at least one piece of information before conducting ve during childbirth the most frequent statement was i want to check you internally while reading the original texts sometimes we noticed a commandlike authoritative style in some of the reported statements for instance come here i want to check you internally raise up your legs and open them and hurry up of all responses related to information statements the most frequent reported response aimed to tell the indication to check your dilation to check your progress the baby was pushing we want to give you artificial labor and to break the water bag total n may exceed 176 as women may have reported more than one response all responses were correct § at least one response was correct ¶ no correct response 30 years old para3 examined 5 times by the same provider reported they never said anything to me she was inserting her finger without saying a word they yelled at me i felt pain and burning then i stopped feeling anything because of the contractions others reported examples of insensitive statements approach or ignorance of womens right to privacy they checked me up internally while i was screaming he yelled at me and the door was open and i was exposed i asked her to cover me up she refused i asked her to close the door she refused discussion our findings suggested a significant association between the high frequency of ve during childbirth and the high number of providers who conduct the exam it highlighted some important gaps in midwifery and medical practices including adherence to the ethical and basic standards of practice midwives rationalized conducting excessive ves due to their workload women request and some midwives reported their discomfort 37 obligation to do it in order not to be accused by physicians and managers for not doing their duties conducting ve by many providers could be related to poorly organized system of care staff responsibilities shift organization and educational purposes so that one important element of childbirth care namely continuity is disrupted continuity of care is core in the midwifery philosophy of practice 38 examining the woman during childbirth several times by the same known compassionate and caring provider in a partnership individualized supportive relationship is probably not as bad as being examined by several people as expected primipara women seems to be examined more frequently unnecessarily than multipara although none of them requested to be examined as per some midwives reports and they were better informed about the exam than multiparous women which could be also related to their longer labor davisfloyd explained the complex symbolic character of the routine ve and concluded that such procedures are being practiced as a ritual 39 reflecting the providers control of the vagina and their insufficient trust that a woman may not dilate on her own without medication 40 this may explain why midwives conduct ve frequently as when they are too busy and too few 34 they might be thinking only at a cognitive level the level at which rituals are accomplished 39 on the other hand the powerful status of palestinian physicians in the health system and in the society 3441 may explain conducting regular scheduled ves during childbirth as an attempt to establish a surveillance and discipline that is referred to by foucault as biopower 42 in the absence of physicians midwives assumed this powerful figure 20 although midwives may be also victims of power as individuals circulate through a networks of threads of power 42 pain feelings during ve were reported by women in previous studies 211 17 18 19 in our study the proportion of women who reported pain seems to be the largest patton and colleagues using a score for pain reported less than a half of their population experienced feelings of pain during ve 10 in a danish study of 1500 teenagers 42 reported feelings of pain and about a half reported painless exam 3 when asked about expectations turkish women did not expect pain during gynecological examination 7 there is evidence that pain during ve may negatively influence the womans future experiences especially if pain experienced in the first exam 3 in our study some women reported pain and discomfort more if the ve performed by physicians and clearly reported a preference of midwives 717 which was consistent with moettus et al 9 who showed an association of pain with providers gender on the contrary some other studies documented no relation between pain 2 or discomfort 6 and provider gender there is evidence that women from western cultures also prefer female provider 6 pain feelings could be related to inadequate hand skills of the examiner medical and midwifery students should be guided throughout their education to acquire the proper competencies to perform this exam with minimal discomfort for women 121420 palestinian women clearly indicated the difference between labor pain and pain from the ve and sometimes they described both which may decrease the possibility of assuming that these women were not aware of what they were feeling allergy to latex gloves during ve is a serious allergic condition that may lead to shock and respiratory distress 43 it is expected that providers identify such cases through their history taking procedure and if allergy to latex is identified ve should be conducted using a nonlatex gloves 43 one main finding suggested that about two thirds of women received no information about ve some women indicated that providers did not talk to them at all before during or after the ve or their ve was conducted in an insensitive manner this indicated insufficient communication of the providers and raises many questions regarding the issue of the implementation of basics of ethics of medical practice informed consent the reproductive rights of women and culture sensitivity the embarrassing sensitive nature of ve for women and providers 20 is particularly true in the conservative arab and muslims cultures where ve is a very sensitive subject to communicate women prefer female providers 44 and do not accept exposing parts of their bodies unnecessarily 29 however womens right to information is protected by the basic human rights conventions 45 and the evidence emphasized the importance of explaining and providing information about ve 717 despite the conservative palestinian muslim culture feeling embarrassed seems to be of less importance for palestinian women compared to womens reports from other countries 3920 embarrassment feelings may have received less attention from palestinian women compared to their feeling of pain discomforts and the insensitive approach they experienced during their ve furthermore the active busy event of childbirth that assumed to have a happy end may distract these women from feelings embarrassed compared to the ve if conducted for gynecological purposes 3 while conducting ve without obtaining informed consent is not an uncommon practice 13 the practice of informed consent is complex 46 in arab countries context sometimes information related to health status is shared with the family members rather than the patient 29 in addition the concept of informed consent in obstetrics implies dimensions of choice autonomy and respect choice and autonomy are two chaotic concepts for women and other individuals in some arab countries as these societies hold great trust in physicians ability to choose the suitable aspects of care for their patients in our study palestinian women accepted frequent ve with minimal or no communication sometimes during contractions accompanied with harsh insensitive approach and pain with no apology and sometimes with negligence of their privacy this raises many questions to what extent the principles of ethics human rights the cultural norms and evidencebased practices are being implemented into practice this necessitates that providers need to adhere to the basics of practices and ethical standards the fundamental steps in nursing and midwifery practices before any procedure suggest the followings ensure privacy prepare the woman for the exam explain the procedure listen and preserve dignity the golden simple rule for the ethical standards is respect the essence of the informed consent which is stemmed from the basics of the human rights adopted by the nuremberg code and the declaration of helsinki in 1949 and 1964 respectively limitations a limitation of this study is that the sample taken from one hospital however the study was conducted in a hospital in which we have tried to change practices in accordance to the best evidence over a 4 years period the data collected for this study was not intended to be used for generalizability but rather to increase our understanding of this practice from the palestinian women perspective conclusions for women childbirth is a lifelong memorable experience ve is another living experience for women during their childbirth may empower them by increasing their selfconfidence or may expose them more in so many ways thus increase their vulnerability it is important that midwives and physicians understand womens feelings and experiences during ve in order to improve their own practices and conduct ve only when necessary carefully without causing pain with minimal discomfort to women and with dignity adhering to best evidence includes that ve during labor is conducted only when necessary and by the same provider as possible according to our finding this shall decrease the number of unnecessary ve during labor and thus decrease the women unnecessary suffering of pain and discomfort during their childbirth process medical and midwifery students should be taught not only to acquire the skill to conduct ve but also should learn how to respect women during this crucial time additional file additional file 1 abstract in arabic language abbreviations ve vaginal examination who world health organization opt occupied palestinian territory competing interests the authors declare they have no competing interests authors contribution sh conceptualized designed the study field work coordination training of field work assistant data collection data analysis interpretation and manuscript drafting revisions and submission js participated in the primary conceptualization analysis interpretation editing and critical revisions of the drafts ah participated in the analysis critical revisions and editing of the drafts eb participated in the primary conceptualization interpretation critical revisions of the analysis and the drafts all authors read and approved the final manuscript

background vaginal examination ve is a frequent procedure during childbirth it is the most accepted ways to assess progress during childbirth but its repetition at short intervals has no value over years ve continued to be plagued by a nature that implies negative feelings and experiences of women the aim of this exploratory qualitative study was to explore womens feelings opinions knowledge and experiences of vaginal examinations ve during normal childbirth methods we interviewed 176 postpartum women using semistructured questionnaire in a palestinian public hospital in the opt descriptive statistics were conducted frequency counts and percentages for the quantitative questions the association between the frequency of ve and age parity years of education locale and the time of delivery was tested by chisquared and fishers exact test the openended qualitative questions were read linebyline for the content and coded the assigned codes for all responses were entered to the spss statistical software version 18 results as compared with who recommendations ve was conducted too frequently and by too many providers during childbirth the proportion of women who received a too high frequency of ves during childbirth was significantly larger in primipara as compared to multipara women p 037 82 of women reported pain or severe pain and 68 reported discomfort during ve some women reported insensitive approaches of providers insufficient means of privacy and no respect of dignity or humanity during the exam conclusions palestinian women are undergoing unnecessary and frequent ves during childbirth conducted by several different providers and suffer pain and discomfort unnecessarily practice implications adhering to best evidence ve during childbirth should be conducted only when necessary and if possible by the same provider this will decrease the laboring womens unnecessary suffering from pain and discomfort providers should advocate for womens right to information respect dignity and privacy

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introduction in todays digital economy internet users are gradually changing from consumers to producers giving rise to the group of playbour playbour is a classification of digital labor digital labor covers a broader range of jobs related to the digital society including physical production line workers who produce digital media tools 1 playbour has two meanings one is the unpaid labor performed by players in video games which is not considered as labor because of its entertainment properties and its value cannot be converted into money however the time and effort spent by a player provides value to both the capitalists of the game development therefore players behavior in the game has been exploited 2 another definition of playbour refers to users who perform all unpaid activities such as publishing their opinions on internet platforms 3 the knowledge and opinions produced by these users have value in themselves and the very act of posting opinions on various portals provides visual benefits to the capitalists of these platforms so this group is also exploited and the value of their labor has been ignored for a long time the content produced by playbour is the cultural knowledge products on the internet platform and the time they spend in using various platforms their production is driven by themselves and there is no external pressure which makes this kind of labor playful in nature the reason why playbour still use social media even though they are exploited is not only the objective condition of not being able to leave social media but also another important reason that playbour are exploited another important reason is that playbour like other types of workers is disciplined by the capitalist system discipline theory first proposed by michel foucault refers to the various rules imposed by the subject of power to control the physical body of the object including the space and time of its activities surveillance and punishment internet social media itself is the object and expression tool of users but after capitalism entered the cyberspace playbour became the object of power and the length and scope of its activities were strictly controlled from platform capitalists 4 this control relies on network surveillance technology the monopoly of users personal data and the design of addictive content whereby capitalism profits from users production and consumption behavior in its platform in this paper we will analyze how internet social media users become playbour and are regulated by platform capitalists through the theory of discipline literature review the term digital playbour was coined by m törhönen l hassan m sjöblom j hamari describing the unpaid informal contributions people make to the creation maintenance and improvement of game content in digital games that are of 5 in 2013 geert lovink and ned rossiter brought the topic into the academy with the publication of the first paper examining the playbour which explored the issue of workforce in games 6 since then the group of playbour has been studied as part of the labour and later developed studies of gender in playbour such as s dargonaki who explored how to achieve gender equality in games and called for game designers to seriously consider the gender of play spaces to create more equal and inclusive play experiences 7 another reification of playbour the act of cultural products produced by users of internet social platforms without compensation in the process of using the platforms was proposed by fuchs of producing content by users as a platform owners unpaid contribution and has a commercial value in the same field van dijck proposes that social media are not isolated technological tools but are shaped by the interplay of various social cultural and political factors and in this way calls for regulation and control of playbour in terms of policy law and social practice 8 in addition couldry n and mejias u a proposes digital colonialism where big data and algorithms collect and analyze playbours data by digital colonialism redefines and formulates playbours identity values and ways of acting while playbour as data producers do not receive any substantial returns from these activities 9 d kelsey and l bennett applies foucaults theory of regulation to the analysis of social media platforms such as youtube facebook and twitter the impact of the auditing system on playbour 10 in addition to this fuchs 2014 book digital labour and karl marx laid the groundwork for a research direction in the field that is closely related to marxism this paper will also analyze the influence of platform capitalists on the use of social media platforms by the playbour group using michel foucaults theory of the discipline methodology discipline is a new term coined by michel foucault to refer to the techniques of power in recent societies this power can intervene train and monitor the flesh as well as produce knowledge the central feature of this technology is normativity in foucaults theory power in the middle ages and before was embodied by punishment which was carried out both physically and mentally in the 19th century prisons symbolizing modern disciplinary techniques came into widespread use and universal surveillance further matured disciplinary techniques bianchin proposed the panoramic openview prison which was designed as a kind of ring prison with all cells facing a central surveillance tower where guards had a clear view of the prisoners activities foucault built on this to create panoptic openviewism in which guards or warders are not present even if they are not and the watched can achieve selfcontrol through surveillance in refining the theory of discipline which has a broad scope of analysis foucault engages in a number of critiques of knowledge illness mental illness rules sexuality discourse and ideology foucaults discussion of social events through the theory of discipline departs from the concepts of subject and economy as a result the academic analysis of social phenomena is no longer bound to psychoanalysis and marxist political economy foucault argues that the initial object of discipline is the human body especially in modern western society which became the primary object of discipline beginning in the 16th century in this period the human body was seen as a malleable material that could be shaped and controlled through various mechanisms and techniques for example medical military and prison institutions controlled and modified the human body through regimentation mechanisms to conform to specific social needs and power relations this regulation and shaping of the body are not only about controlling the body but also involve constructing the subjects identity and body as the social structure develops and the need for regulation increases the object of regulation is no longer just the human body and behavior the object of regulation gradually expands from the body to a broader social sphere including thought speech behavior and culture in his writings foucault emphasizes the power of knowledge and the intellectuality of power that is power and knowledge are interpenetrating and interactive through the production and control of knowledge power can shape and control the functioning and behavior of society at the same time knowledge itself is influenced by power and different power relations and practices can lead to different ways of producing and disseminating knowledge discipline is usually exercised by the subject of power over the object through discipline in the case of physical discipline the disciplinary agency classifies and standardizes the population and monitors punishes regulates and trains at the mental level the disciplinary agency achieves the purpose of disciplining the object through the production of discourse and knowledge by constructing a discourse that the subject of power identifies with after a long period of domestication the disciplinary society will be transformed into what deleuze calls a selfcontrolled society ie the object of power will spontaneously identify with the ideology being disciplined even if the subject of power no longer gives orders the objects of power will control themselves monitor and control each other and thus the social ideology will converge with the expectations of the subject of power 11 in discipline and punish the purpose of discipline relies on spatial distribution temporal arrangement activity control and punishment to achieve it 12 in the archaeology of knowledge foucault proposes discursive discipline to complement the scope of discipline 13 because of the virtual nature of the internet social platform users are not forced to use it so discipline is accomplished in a more covert way in this context covert means that platform capitalists already have a mechanism in place to compel users to behave according to the platforms expectations before they are disciplined to do so after a long period of disciplined behavior the users of the platform develop addictive habits and identify with certain rules and the entire user ecology of the platform moves towards what derrida calls selfcontrol even if the platform no longer restrains users various behaviors users will still exercise selfrestraint and mutual restraint body from user to playbour the regulation of users by internet social platforms has not existed from its inception as a tool for users to express themselves the social platform was initially an object of power while the users were the subject of power after platform capitalists intervened platform capitalists became the subject of power and social platforms became the tools for platform capitalists to discipline users in this power relationship users become the object of power therefore the regulation of users by internet social platforms is experienced as an exchange of power subjects and objects scholar van dijck points out that social media are not isolated technological tools but are shaped by the interplay of various social cultural and political factors in his interpretation of social media social media as a whole has taken on attributes beyond tools but on specific social platforms it can only be called playbour when the user becomes an object of power in the first stage of the development of internet social platforms when they did not hold a certain market share platforms needed to transfer power to users in order to attract more users at this stage the platform is not profitable and the content posted by users and the act of interacting with each other on the platform brings usage and online activity to platform capitalists though however at this stage the content produced by users did not translate into real capital wikipedia is a representative example of this with content compiled by users themselves wikipedia also encourages users to communicate through other platforms such as some pages that provide the names of telegram group chats that users form themselves wikipedia does not monetize its users and therefore does not need to limit all users actions to its own platform thus wikipedia becomes a space for users to exchange information resources when this information is rich enough to form a knowledge graph it attracts more users to supplement and expand its own information content and system after the first phase when platform capitalists have a large number of users and a certain market share they start to reclaim their power in order to reach profitability what determines whether the platform is profitable or not is the content that playbour creates on the platform for free of course in foucaults theory of regulation whether a social platform exists as an object does not depend entirely on whether the platform capitalist is profitable or not but should focus more on the owner of power when the power of the platform is much greater than that of the user it means that the position of the subject and the object has changed take douban a social networking site from china for example whose early operation model was also decentralized without the involvement of the platform the platforms communication is based on users creating their own groups and recruiting users who are interested in a certain topic for internal discussions however after the platform gained a certain number of users the platform operator has repeatedly rectified or removed the platforms functions and userproduced content in order to achieve the platforms speech environment expected by the capitalists douban shares similarities with another social platform from china baidu post both platforms have been owned by companies under the capitalist system since their inception at the beginning of the development of these two platforms the power of platform capitalists was less than that of users when the development reached a later stage both platforms found their own platform characteristics through their own user characteristics in recent years many internet social platforms will make user portraits of their own platform users in their yearend summaries which is a direct reflection of platform regulation playbours process of being disciplined as mentioned above the environment in which playbour is produced is a virtual space and playbour is not forced to use a certain platform so platform capitalists discipline is not directly effective under this situation platforms initiatives to make users use it consistently over time are a necessary prerequisite for the platforms discipline of playbours discipline is a necessary prerequisite for its implementation and is one of the components of the discipline however because the purpose of these platforms in providing codes of conduct is to make it easier to manage users these rules are flexible in practice and are mainly aimed at ensuring that playbour does not make statements that are detrimental to the platform in most platforms nonmainstream political ideas are deleted or the account posting the content is banned once it is published on some platforms where the founder is well known if the content is openly critical of the founder it will also be deleted or not even reviewed these platforms control over playbours speech makes the platform a site of power relations and the platform operator is the representative of the power structure the playbour as the producer and the regulated party does not accept this regulation completely but resists it through various means for example using homophones to replace some sensitive words or building a set of vocabulary shared among platform users to metaphorically describe things that are not allowed to be discussed on the platform in the process of resistance playbour also confirms and shapes its own subjectivity making playbour have a deeper understanding and control over its own behavior when playbour is a consumer he usually spends money on social platforms in two ways the first is to make online purchases directly through the mall contained in the social platform itself the platform then regulates this group through the allocation of space and the division of time in the online shopping pages various functions construct a new space people will spend time browsing these pages and will make the same actions under some specific instructions eventually placing orders on the platform and becoming consumers the space allocation of a platform depends largely on its page presentation take taobao a chinese ecommerce and social platform for example the bottom of the taobao homepage has five functional partitions the first two buttons function as product feeds the merchants dialog box is in the center followed by the shopping cart and finally the aftersales service the space distribution reserves a lot of space for product display and users can browse an endless number of pages the arrangement of functions basically follows the steps of product exchange ie selecting products buying products and aftersales service providing convenience for users like taobao tik tok and kwai are other chinese platforms that combine shopping and social networking in foucaults theory of discipline the subject of power establishes a precise schedule of what the disciplined must do and makes the disciplined accustomed to this arrangement through constant repetition in addition to schedules temporal regulations should be made for actions so that time can penetrate the flesh of the disciplined in the online shopping platform the platform party cannot blatantly set up a schedule for the users and require them to complete some tasks at a specific time so the platform will set some rewards or develop some minigames to increase users browsing and time spent on the platform take taobao as an example playbour can get product coupons or other freebies if they reach achievements in some games they set up in tik tok playbour can get cash for videos of sufficient length but they need to reach a fixed amount before they can be distributed this activity combines both properties of playbour in addition to regulating plybour to use the platform with a steady frequency and spend money on it and by setting up games so that the playbour community continues to be productive on the platform the result of playbours discipline the tendency to worship commodities the concept of commodity fetishism was introduced by marx in capital referring to the fact that in capitalist society people see commodities as objects with mysterious power believing that their value lies not in their use value but in their exchange value thus giving them a supernatural power 14 in commodity fetishism people see the price of commodities rather than their use value which makes commodities themselves a mysterious thing with supernatural power and value under this notion commodities seem to have the ability to reproduce themselves rather than being produced by humans as a result what the internet social platform is to playbour has the tendency to be a myth as mentioned earlier different platforms draw user profiles for their users user persona is the process of characterizing users through research observation and analysis of target users the purpose is to better understand user needs habits behaviors and attitudes in order to better design and provide products and services usually user profiling includes information about users basic information habitual behaviors needs and pain points etc unlike traditional enterprises internet social platforms generate usage reports from user profiles and release them separately to users in the form of usage reports at the end of the year the first internet platform to enable yearend usage reports was facebook in 2013 with its year in review feature which shows users the most important moments posts and photos from the past year on facebook since then many platforms have developed this feature some platforms such as have further expanded the public scope of their user profiles they withhold information about users and post the average age frequently searched terms and common expressions of platform users on their websites these tags cater to users categorization and generalization psychology and social identity psychology in turn the terms frequently used by users on a platform increase peoples identification with that platforms community take the example of bilibili a chinese video site each year the platform publishes its buzzwords of the year which are mostly created by users and are then certified by the platform for wider use the platforms users are proud of the fact that their words are part of the culture of the platform since many platforms have a highly identifiable user base some users may unconsciously divide themselves into camps when using different platforms considering themselves to belong to a certain platform and labeling other platforms as stereotypes for example kwai is often seen as uneducated because of the average age of its users douban is seen as a feminist platform because its users are mostly women therefore different types of users also tend to choose which platforms to use by these labels in this segment the platform is not just a tool but functions more like a church where people with the same ideology gather to communicate with each other users inject ideology into the platform but use it because it covers people with that ideology and see it as a symbol of a certain ideology outside the platform a process of alienation of users as playbour all the contents presented on the platform are produced by the playbour but the playbour sees these produced discourses as higher than its own will and this is the result of the playbour being regulated conclusion the process of playbour being regulated by the internet social platforms undergoes a shift in the power subjectobject relationship during the immature period of the platforms the people who used these platforms were just ordinary users after the platform capitalists interfered with the users the users lost their sovereignty and were regulated by them thus becoming playbour eventually the group of playbour would go to commodity worship as the platform matured and the platform completed the transformation from a tool to a god the whole process of regulating users by the platform is carried out under the operation of capitalism and there is no way to reverse the fate of users becoming playbour and being exploited if we want to change this situation we need to develop the internet social media platforms into the users own platforms this needs to be studied from the perspective of platform capitalism which is not covered in this paper and can be discussed in future study initial period when social media platforms are first established they invite a large number of celebrities in order to attract users and enhance the visibility of the platform in foucaults discourse regulation theory this is a manifestation of regulation through knowledge different social media platforms will invite celebrities from different fields according to their own positioning twitter for example was one of the first social media platforms to invite celebrities as a microblogging and social networking service twitter invites celebrities in the entertainment industry such as ashton kutcher justin bieber and katy perry zhihu a social q a site invites resident celebrities from different fields of knowledge such as olympic champion sun yang and tsinghua university professor wu jun unlike ordinary users the presence of these invited celebrities on social media platforms and the content they produce can be directly translated into real capital ie they bring a lot of users and attention to their platforms these resident celebrities are themselves the spokespersons of the social media platforms and the knowledge they possess is produced through a specific platform which means that the platform has the knowledge and the right to speak thus playing a role in regulating ordinary users midterm period in order to increase user stickiness platforms usually adopt strategies such as providing personalized content and offering personalized settings this can effectively increase users comfort level but is predicated on the platforms possession of users personal information and browsing data although in some regions platform operators are required by law not to disclose user information users are well aware that their information is known to the platform regardless of whether the platform party may disclose it in the case of social media for example according to scholar andrejevic social media platforms can be considered prisons this is because they impose a series of regulations and restrictions on usergenerated content to ensure that the content is in line with the platforms interests and policies in this process the platforms take control over the users and they become the objects of regulation according to foucaults panoptic openmindedness to explain this phenomenon the user is a prisoner under surveillance the platform operator who has information about the users and can punish them when they violate the norms of the platform is the invisible prison guard of the prisoners in fact this view is not exactly a metaphor using the social media platform as an ontology and the prison guard as a metaphor in fact there are indeed cases where the police are livestreaming on social media on one chinese livestreaming platform the police arrested the culprit through the ip address provided by the platform while the grave robber and the cultural relics expert were connected to identify the stolen relics post period when users use an established internet social platform they are essentially engaging in unpaid content production whether they are posting information for all users through that platform or engaging in other private activities such as shopping or private socializing through that platform these platforms turn usergenerated content into commercial profits and this commercialization process makes users a mix of producers and consumers in the process of use playbour also faces various forms of regulation imposed by the platform the next section will analyze playbour through both situations as producer and consumer when playbour acts as a producer the content they produce is subject to strict scrutiny most internet social platforms provide users with a set of written instructions on standards of behavior that prohibit inappropriate speech and this standard usually depends on laws and some moral concepts that generate consensus at the social level this does not mean that censorship is just or perfect

playbour as a new type of digital labor is commonly exploited and involves everyone using the internet social platforms the present study will mainly analyze how playbour is regulated by platform capitalists based on michel foucaults theory of regulation and the regulation process will be presented in the early middle and mature stages of platform development in the early stage the platform is immature in order to attract users the platform will give them a high degree of sovereignty in the middle stage platform capitalists gradually reclaim their sovereignty and the user becomes less autonomous thus becoming a playbour in the later stage the playbour becomes an object of the platform and loses its sovereignty completely in the cyberspace after being disciplined by the platform platform capitalists the purpose of disciplining the playbour is to increase the viscosity of users to the platform and to produce a constant stream of new cultural products for its profit through this analysis this paper argues that such regulation not only exacerbates playbours exploitation but also leads users towards commodity worship and deification of the internet social media platform the ideological and linguistic culture of the labor community will be hit hard by such an impact this paper attempts to argue the seriousness of the problem through analysis

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introduction why do some chil dren leave the paren tal home as soon as pos si ble whereas oth ers delay their nest leav ing to a later age is the nestleav ing deci sion driven by purely cul tural fac tors or do eco nomic con sid er ations play a role answering these ques tions is impor tant because the nestleav ing age mat ters for eco nomic and social out comes through out the life course for exam ple billari and tabellini found that ital ians who leave the paren tal home ear lier in life have higher incomes in their mid30s when cou pled with late fam ily for ma tion and late entrance into the labor mar ket late nest leav ing may be asso ci ated with lower or post poned fer til ity and a shorter work ing life with neg a tive con se quences for the sus tain abil ity of pen sion sys tems as well as for indi vid ual pen sion wealth accu mu la tion whereas the sociodemographic lit er a ture has stressed the role of cul tural fac tors in explaining nestleav ing pat terns the eco nom ics lit er a ture has inves ti gated the impor tance of fnan cial resources manacorda and moretti found that ital ian par ents pre fer to coreside with their chil dren and there fore may reward them fnan cially for stay ing in the paren tal home a 500 increase in paren tal income is asso ci ated with a 35 to 39per cent agepoint increase in the prob a bil ity that adult chil dren will live with their par ents as the authors noted how ever this result is unlikely to hold for countries in central and northern europe which have dif fer ent cohab i ta tion pref er ences another strand of the eco nom ics lit er a ture has exam ined the role of the youn ger gen er a tions lim ited access to the hous ing mar ket capital and hous ing mar ket imper fec tions may indeed delay nest leav ing but this effect might be stron ger for chil dren who grew up in poorer fam i lies who can not rely on their par ents for help fnd ing suit able accom mo da tions in fact cobbclark and gørgens showed that wealth ier par ents are more likely to offer hous ing sup port and fnan cial gifts to their young adult chil dren in this study we focus on the role of child hood stan dard of liv ing on the nest leav ing deci sion we use data from the survey of health ageing and retirement in europe on a rep re sen ta tive sam ple of indi vid u als aged 50 or older liv ing in one of 28 euro pean countries or israel the data con tain ret ro spec tive infor ma tion on socio eco nomic con di tions at age 10 age at nest leav ing and other major life events our inter est lies in the rela tion ship between the age at nest leav ing and socio eco nomic con di tions at age 10 we pro vide strong evi dence of a pos i tive rela tion ship between socio eco nomic con di tions at age 10 and the age at leav ing the paren tal home the size of the effect dif fers some what across gen ders and cul tures but the sign and sig nif cance of the key esti mated coef f cient remain the same across dif fer ent groups looking at mech a nisms we fnd that edu ca tion only par tially medi ates the effect of a golden nest on leav ing the paren tal home we also show that a stan dard strippeddown ver sion of the life cycle model with three peri ods can eas ily explain why grown work ing chil dren of afflu ent par ents leave home later we assume that grown chil dren who live at the paren tal home while work ing pass their earn ings on to the par ents and have the same stan dard of liv ing as in their child hood we also assume that the age pro fle of earn ings is upward slop ing so that income dur ing the frst period of the model is lower than the con sump tion level in the paren tal home if the chil dren move out they can use their cur rent and future earn ings to smooth con sump tion over the whole life cycle in this con text we show that grown chil dren will move out sooner if the stan dard of liv ing at the paren tal home is lower however if the paren tal home is suf f ciently attrac tive in terms of con sump tion they will delay home leav ing we also add habitforming pref er encesthat is a spec i f ca tion of the util ity func tion that assumes that cur rent util ity depends on the gap between cur rent and past con sump tionto our nestleav ing model and show that this spec i f ca tion rein forces the depen dence of the nestleav ing deci sion on the child hood con sump tion level our empir i cal con tri bu tion lies in show ing that chil dren of high socio eco nomic sta tus leave home later in many countries irrespective of their cul ture and that this effect is only partly due to edu ca tion our the o ret i cal con tri bu tion con sists in the longterm consequences of a golden nest pro vid ing evi dence that late nest leav ing can be explained as a com bi na tion of a taste for con sump tion smooth ing and access to eco nomic resources this induces chil dren who grow up in highses fam i lies to leave the paren tal home later in line with what we observe in the data data we use data from the survey of health ageing and retirement in europe a bien nial sur vey that col lects infor ma tion on euro pe ans aged 50 or older as of this writ ing the sur vey has col lected eight waves of data we use data from the third and the sev enth waves of share release 710 containing ret ro spec tive life course infor ma tion on all respon dents these data known as sharelife data cover 28 euro pean countries plus israel they con tain infor ma tion on sev eral indi ca tors of the stan dard of liv ing at age 10 includ ing the num ber of rooms per cap ita the num ber of books at home the house holds num ber of ame ni ties and the occu pa tion of the house holds main bread win ner in addi tion infor ma tion on whether the area of res i dence at age 10 was urban or rural is also avail able furthermore the data also report the year each indi vid ual left the paren tal home this infor ma tion allows us to inves ti gate age dif fer ences at nest leav ing the ini tial sam ple includes all indi vid u als who com pleted a sharelife inter view in wave 3 or if they were not yet part of the sur vey at that time wave 7 we keep only those born in 19361956 to avoid issues of selec tive mor tal ity and to obtain a sta ble gen der bal ance across cohorts we omit 4528 indi vid u als who were not born in the cur rent coun try of res i dence to avoid issues of endog e nous mobil ity reduc ing the sam ple size to 54394 we also omit records with miss ing or implau si ble infor ma tion on nestleav ing age or with miss ing or implau si ble infor ma tion on age at frst cohab i ta tion the sam ple size after all these selec tions is 53214 we fur ther omit 10865 indi vid u als with miss ing infor ma tion on covariates about child hood the bind ing con straint is paren tal occu pa tion because the ses dis tri bu tion has a long but very thin right tail we elim i nate out li ers on this var i able using tukeys pro posed cri te ria1 this restric tion results in omit ting 165 obser va tions in the right tail of the dis tri bu tion and no obser va tions in the left tail the fnal sam ple con tains 42184 obser va tions 2 following mazzonna we con struct a gen eral index for child hood ses using infor ma tion on indi vid u als stan dard of liv ing at age 10 this method is stan dard among research ers using share data given that the sur vey min i mizes recall bias by not ask ing respon dents to pro vide infor ma tion on paren tal edu ca tion or income when they were young two stan dard mea sures of fam ily back ground used in the lit er a ture on inter gen er a tional trans mis sion 3 we con struct our index using polychoric prin ci pal com po nent anal y sis to extract the frst com po nent from the fol low ing four prox ies of ses occu pa tion of the main bread win ner the num ber of rooms per cap ita the num ber of books at home and the num ber of house hold ame ni ties given that some of these var i ables are related to insti tu tional fac tors spe cifc to indi vid ual countries such as run ning water or cen tral heating for indi vid ual dwell ings we demean each var i able within countries before com put ing the index consistent with mazzonna we obtain only one prin ci pal com po nent with an eigen value above 1 which explains more than 40 of the total var i ance the signs of the scor ing coef f cients are also con sis tent we esti mate a neg a tive load ing for low paren tal occu pa tion and pos i tive load ings for the other var i ables as shown in table 1 which dis plays descrip tive sta tis tics for the key var i ables used in this study we stan dard ize the resulting index to have a zero mean and unit stan dard devi a tion in the full sam ple the dis tri bu tion of the index for the full sam ple displayed in figure 1 is rightskewed and has a very gran u lar nearly con tin u ous sup port thereby pro vid ing a rich descrip tion of the var i abil ity in ses table a2 in the online appen dix reports var i a tion in the index in each coun try our depen dent var i able is the age at nest leav ing obtained from responses to the fol low ing ret ro spec tive ques tion in which year did you start to live on your own or as an alter na tive out come var i able we use age at frst cohab i ta tion with a part ner ninetysix per cent of our sam ple had cohabited with a part ner by age 49 and the con di tional aver age age at frst cohab i ta tion is approx i ma tely 24 years in addi tion roughly one fourth of nest leav ers did so as sin gles and the remaining three fourths left the paren tal home to start cohabiting with their frst part ner other var i ables used in our anal y sis are gen der year of birth lived in a rural area at age 10 never had sib lings and lived with out at least one par ent at age 10 we also con trol for selfreported math and lan guage abil ity at age 10 expressed in terms of being much bet ter bet ter about the same worse or much worse than ones class ma tes for both sub jects roughly 50 reported being about the same as their peers but less than 15 reported being worse or much worse than their peers in some of our ana ly ses we also explore the medi at ing effect of edu ca tional achieve ment our sam ple com pleted an aver age of 11 years of edu ca tion 4 table 1 also reports the dis tri bu tion of the sam ple by wave 18 of the sam ple was pres ent only in wave 3 and 59 of the sam ple par tic i pated only in wave 7 the remaining 23 of respon dents par tic i pated in both waves the effect of ses on nestleaving age main estimates the thought exper i ment we would like to con duct to iden tify the effect of ses on nest leav ing would be to ran domly allo cate at birth two iden ti cal twins to two fam i lies with dif fer ent lev els of ses and com pare their nestleav ing deci sions we mimic the longterm consequences of a golden nest this exper i ment with our obser va tional data by esti mat ing ordi nary leastsquares regres sions of the age at nest leav ing on child hood ses con trol ling for inter view wave liv ing in a rural area at age 10 selfreported abil ity in math and lan guage at age 10 never had sib lings and lived with out at least one par ent at age 10 we also include gen der year of birth and coun try dummy var i ables controlling for rural res i dence and gen der is impor tant because age at nest leav ing varies across these char ac ter is tics indi vid u als from rural areas leave the nest about one half year later than those from urban areas and females leave the paren tal nest roughly two years sooner than males including mea sures of math and lan guage abil ity helps assuage con cerns about selfsorting into edu ca tion due to higher abil ity and hence the post pone ment of nest leav ing and con trol ling for fam ily struc ture is impor tant because it deter mines the avail abil ity of care cohort dummy var i ables are cru cial to con trol for macrolevel shocks that are com mon to all countries whereas coun try dummy var i ables account for all coun tryspe cifc cul tural and insti tu tional fac tors in some spec i f ca tions we also include either coun tryspe cifc lin ear cohort trends or inter ac tions of cohort gen der and coun try dummy var i ables these trends and inter ac tion terms con trol for coun tryspe cifc changes in ses and nestleav ing age that took place over time as well as for changes in mac ro eco nomic and insti tu tional fac tors that vary by cohort coun try and gen der finally we also include inter view wave dummy var i ables to account for time effects table 2 reports the ols esti ma tes of the effect of ses at age 10 in three spec i f ca tions with heteroskedasticityrobust stan dard errors shown in paren the ses column 1 includes the indi vid uallevel observ able con trols and coun try and cohort dummy var i ables columns 2 and 3 include addi tional var i ables coun tryspe cifc lin ear cohort trends in col umn 2 and the inter ac tion among year of birth coun try and gen der dummy var i ables in col umn 3 these regres sions are esti mated on the sam ple that excludes the 934 indi vid u als who had not left the paren tal home by age 49 however we also esti mated an ols regres sion model for the prob a bil ity of nest leav ing by age 49 using the same spec i f ca tion adopted in col umn 2 of table 2 reassuringly we found no effect of ses at age 10 on this prob a bil ity the results are remark ably sta ble across col umns focusing on the point esti mate in col umn 2 we see that a high ses in child hood makes an indi vid ual post pone nest leav ing by roughly half a year com pared with a low ses in child hood although ses at age 10 may imper fectly cap ture ses at poten tial nestleav ing ages this source of mea sure ment error would cause atten u a tion bias and imply that our point esti ma tes can be interpreted as a lower bound for the true effect heterogeneous effects to assess whether our main result in the full pop u la tion applies in gen eral or is spe cifc to pop u la tion sub groups we con duct sev eral het ero ge ne ity ana ly ses using our base line ols spec i f ca tion reported in col umn 2 of table 2 the results of these ana ly ses are shown in table 3 5columns 1a and 1b show that although females are sig nif cantly more sen si tive to child hood ses the pos i tive effect of child hood ses on nestleav ing age holds for both gen ders similarly col umns 2a and 2b show that the child hood ses effect holds across urban and rural res i dence at age 10 but those who lived in an urban area were more sen si tive to child hood ses columns 3a 3b and 3c report het ero ge neous effects by the main cul tural fea tures of the coun try of res i dence in child hood following inglehart and welzel we clas sify each coun try in our sam ple into one of three cul tures as fol lows • cath o lic austria spain italy france greece belgium israel ireland luxembourg portugal cyprus and malta • excom mu nist the for mer east germany the czech republic poland hungary slovenia estonia croatia lithuania bulgaria latvia romania and slovakia and • protestant the for mer west germany sweden the netherlands denmark switzerland and finland we fnd that although the pos i tive and sig nif cant effect of child hood ses is sig nif i cantly smaller in mag ni tude in protestant countries it is not pecu liar to cath o lic countries but is gen er al iz able to the entire set of euro pean countries con sid ered in this the longterm consequences of a golden nest study 6 therefore our results are not driven by the fact that par ents in some cul tures might see coresidence with their adult chil dren as a nor mal good and bribe their chil dren to stay at home with them as in the case of italy in addi tional ana ly ses we also esti mated het ero ge neous effects by cohort coun try of birth birth order 7 whether subjects had siblings whether subjects lived with out at least one par ent at age 10 and a selfrated assess ment of whether either par ent ever harmed them phys i cally in child hood in all cases we found a pos i tive effect of child hood ses and no evi dence of sig nif cantly het ero ge neous effects the lack of het ero ge neous effects across cohorts speaks in favor of the exter nal validity of our main result respondents born in 19361945 left the paren tal home pri mar ily dur ing the period of eco nomic growth that europe expe ri enced in the 1950s1960s and those born in 19461956 left home dur ing the oil cri sisinduced reces sions of the 1970s our fnd ings thus sug gest that our main result holds irrespective of the prevailing mac ro eco nomic con di tions the mediating role of education individuals with high ses in child hood are likely to acquire more edu ca tion and may choose to post pone fam ily for ma tion to com plete their edu ca tion we there fore inves ti gate the medi at ing role of edu ca tion in explaining the rela tion ship between child hood ses and nestleav ing age in line with the stan dard approach to medi a tion anal y sis we assess the impact of child hood ses on years of edu ca tion the impact of years of edu ca tion on nestleav ing age con di tional on child hood ses and there fore whether the impact of child hood ses on nestleav ing age is explained entirely by its indi rect medi at ing effect on edu ca tion or whether there is also a direct link between child hood ses and nestleav ing age following baron and kenny the total effect of child hood ses on nest leav ing age can be writ ten as the sum of a direct and an indi rect effect the indi rect effect which is medi ated by edu ca tion is obtained as the prod uct of the effect of child hood ses on edu ca tion and the effect of years of edu ca tion on nestleav ing age as a result the direct effect would be zero if the effect of edu ca tion on nestleav ing age were large enough to make the indi rect effect of ses on nestleav ing age equal to the total effect for a given effect of ses on years of edu ca tion hence the effect of years of edu ca tion on nestleav ing age that would lead the direct effect of ses on nestleav ing age to be equal to zero is given by the ratio between the total effect of ses on nestleav ing age and the effect of ses on years of edu ca tion given that some countries might dis play regional var i a tion in the prevailing reli gion we also adopted a slightly dif fer ent def ni tion of cul ture that codes as cath o lic the ger man länder of bavaria rheinland palatinate nordrheinwestfalen and badenwürttenberg the southern region of the netherlands and the french and ital ianspeak ing can tons of switzerland this def ni tion pro duced com pa ra ble results although the dif fer ences between protestant and the other countries were no lon ger sig nif cant 7 this infor ma tion is not avail able for 6227 obser va tions mostly belong ing to the wave 7 only sam ple which were dropped for this anal y sis the longterm consequences of a golden nest the results of our medi a tion anal y sis are reported in table 4 column 1 reports the total effect of child hood ses obtained from our base line spec i f ca tion in col umn 2 of table 2 column 2 of table 4 uses the same empir i cal spec i f ca tion and shows that highses indi vid u als obtain more years of edu ca tion column 3 dis plays the effect of years of edu ca tion on nestleav ing age and the addi tional con trols included in our base line spec i f ca tion this effect is pos i tive and sig nif cant one addi tional year of edu ca tion leads indi vid u als to post pone nest leav ing by 007 years the indi rect effect of child hood ses on nestleav ing age is obtained as the prod uct of the effect of ses on years of edu ca tion shown in col umn 2 and the effect of years on edu ca tion on nestleav ing age shown in col umn 3 this effect is equal to 0069 years for a 1 stan dard devi a tion change in ses and is sta tis ti cally sig nif cant table 4 also shows that the direct effect of child hood ses reported in col umn 3 holds even after we take into account the medi at ing effect of edu ca tion however this direct effect is sig nif cantly smaller than the total effect reported in the base line model in col umn 1 suggesting that edu ca tion par tially medi ates the effect of child hood ses on nestleav ing age one empir i cal dif f culty in car ry ing out this exer cise relates to the poten tial endog eneity of years of edu ca tion as there may be omit ted unob serv able traits that jointly deter mine both edu ca tional achieve ment and nestleav ing age as shown by the directed acy clic graph shown in figure 3 thus far we have assumed selec tion on observ able char ac ter is tics we have assumed that the con trols included in our model are such that the remaining var i a tion in years of edu ca tion is as good as ran dom however we can assess the sen si tiv ity of our esti ma tes to selec tion on unob serv able char ac ter is tics using osters pro por tional selec tion test devised fol low ing the logic of altonji et al this test aims to assess how strong the impact of unob served var i ables would have to be with respect to the impact of observed var i ables to drive our esti mated treat ment effects down to zero we let δ indi cate this ratio of pro por tional selec tion 8 for exam ple δ 1 would imply that the impact of unob serv able char ac ter is tics should be as large as the impact of the included con trols to nul lify our esti mated effect δ 1 is also the thresh old altonji et al suggested using to rule out that the bias due to omit ted unob serv able char ac ter is tics is strong enough to explain away the esti mated effect the last col umn of table 4 shows the value of c for the esti mated effect of edu ca tion on nestleav ing age and the direct effect of ses on nestleav ing age the frst test cor rob o rates our strat egy to esti mate the effect of edu ca tion on the 8 let us assume the fol low ing sim ple model y βx γw 1 w 2 ε where x is the treat ment w 1 is an observ able con trol and w 2 is an index of unob served con trols the pro por tional selec tion rela tion ship is then δ cov var cov var where δ is the coef f cient of proportionality the test works by com put ing the value of δ for which β would be 0 under the assump tion that w 1 ⊥ w 2 to con duct this test we need to state a max i mum attain able value of the r squared which indi cates the max i mum share of var i ance of the out come that could be explained by any set of observ able and unob serv able covariates following osters sug ges tions we set the value of r max to 13 times the value of the r squared of the model that includes all the observ able con trols controls unobservable characteristics ses at age 10 nestleaving age education fig 3 mediating role of education the longterm consequences of a golden nest depen dent var i able the sec ond test is more directly rel e vant for our case given that we are inves ti gat ing the medi at ing effect of edu ca tion the results show that the esti mated value of δ for the esti mated effect of edu ca tion on nestleav ing age in col umn 3 is larger than 1 put ting us in a safe posi tion according to the thresh old altonji et al pro posed by con trast δ is very large and neg a tive for the effect of child hood ses on nestleav ing age hence the effect of ses on nestleav ing age could be driven down to zero by the pres ence of unob serv able char ac ter is tics only if these char ac ter is tics were much more rel e vant driv ers of selec tion bias than the included con trols and their cor re la tions with ses were of the oppo site sign with respect to one of the included con trols this pos si bil ity is implau si ble because our set of con trols is rather com pre hen sive robustness tests before presenting our eco nomic model we report the results of sev eral sen si tiv ity tests that sup port the robust ness of our pre vi ously presented results first our base line ols esti ma tes in table 2 are obtained from the sam ple of 41252 sub jects who left the paren tal home by age 49 to safe guard against this poten tial cen sor ing prob lem we repeat our main anal y sis using a logis tic regres sion to esti mate a dis crete dura tion model for the prob a bil ity of nest leav ing at any given age con di tional on not hav ing left already unlike the ols regres sion this model uses infor ma tion on all 42184 indi vid u als however because each indi vid ual con trib utes an obser va tion for each year from age 14 until nestleav ing age or until 49 if the indi vid ual has not left yet the panel esti ma tion sam ple has 451563 obser va tions in these equa tions we use the same set of timeinvari ant con trols as in the ols regres sions as well as stan dard error esti ma tors that are robust to heteroskedasticity table a3 in the online appen dix dis plays esti ma tes of the effect of ses on the odds ratio of nest leav ing for three spec i f ca tions that dif fer with respect to the func tional form cho sen for the base line haz ard and for the set of trends and fxed effects included as reported at the bot tom of each col umn all col umns include the indi vid ual level observ able covariates included in our main spec i f ca tion in table 2 in all cases the key param e ter is sig nif cantly smaller than unity indi cat ing that chil dren from a higher ses leave the paren tal nest later figure a1 in the online appen dix shows the esti mated haz ard rate and sur vival func tion by ses resulting from the model shown in col umn 1 of table a3 these esti ma tes are aver ages obtained after we assign ses 1 and ses 1 to all units in the sam ple the results show that the haz ard rate is always higher for lowses indi vid u als and the dif fer ence between groups peaks at around age 25 second we rep li cate the ols anal y sis shown in table 2 but intro duce all four mea sures of ses at age 10 that we use to build our index instead of using the index itself the results shown in table a1 in the online appen dix indi cate that each mea sure attracts a sig nif cant coef f cient suggesting that no sin gle facet of ses is driv ing our results finally we address a remaining con cern about our esti ma tes on the medi at ing role of edu ca tion some indi vid u als may have answered the ques tion on nestleav ing age by reporting the year when they left home to attend a uni ver sity if so then our results might be picking up an effect of edu ca tion on nestleav ing age that is smaller than it should be given that indi vid u als with more edu ca tion would report leav ing home ear lier than they should although this pat tern is not very com mon in our data we con duct a robust ness check to dis pel this con cern we rep li cate the exer cise shown in table 4 this time using age at frst cohab i ta tion as the depen dent var i able because it refers to a spe cifc liv ing arrange ment this mea sure is less ame na ble to a sub jec tive inter pre ta tion of nest leav ing reassur ingly the results are wholly con sis tent with our ear lier fnd ings if any thing we obtain larger coef f cients of pro por tional selec tion lend ing greater sup port to our empir i cal strat egy model and simulation results to pro vide an eco nomic expla na tion of our robust fnd ing that a golden nest delays nest leav ing we con sider a life cycle model in which the young base their nest leav ing deci sion on the util ity they enjoy dur ing their life time for sim plic ity we con sider a threeperiod life cycle model period 0 is child hood and is predetermined the child hood con sump tion level is out side indi vid u als con trol in period 1 the young peo ple can choose whether to stay in the paren tal home or to leave individuals who stay share any income with their par ents and con sume the same amount as in their child hood individuals who move out smooth their resources across all three peri ods in period 2 we assume that no child remains with their par ents in this con text indi vid u als always leave home in period 1 if their income in that period is higher than their child hood con sump tion level this result is not sur pris ing because nest leav ing allows them to enjoy higher life time resources and the free dom to opti mize con sump tion and sav ing deci sions over their entire adult hood if indi vid u als income in period 1 is instead lower than their child hood con sump tion life time resources would be higher if they stayed with their par ents in period 1 however nest leav ing may still be attrac tive if their period 1 income is just below their child hood con sump tion because nest leav ing con fers the pos si bil ity to smooth con sump tion a numer i cal exam ple helps explain why assume the inter est rate equals the time pref er ence param e ter so the opti mal plan is char ac ter ized by the same con sump tion level across peri ods assume that the util ity func tion is well behaved func tion in our numer i cal sim u la tions suppose that income is increas ing with age such that it is 05 in period 1 1 in period 2 and 15 in period 3 if c is 06 then nest leav ing is opti mal because indi vid u als can con sume 1 in all three peri ods however if c is 09 the nestleav ing con sump tion pro fle of will be less attrac tive than the homestay ing pro fle of for sen si ble pref er ence param e ters we also add hab its to our nestleav ing model the stan dard way in which hab its are mod eled is that util ity is affected by a stock of hab its that depends on past con sump tion rational con sum ers will take this depen dence in con sid er ation when decid ing todays con sump tion we show that hab its rein force the depen dence of the the longterm consequences of a golden nest nestleav ing deci sion on the child hood con sump tion level in our model we fol low angelini and defne period util ity over the cur rent period and the pre vi ous period con sump tion u t u a com monly adopted spec i f ca tion is u t u where 0 ≤ γ 1 denotes the force of hab its u t could be of the cara type as in angelini u t 1 θ e θ 1 where θ is the abso lute riskaver sion param e ter we defne nl 1 if the con sumer leaves the paren tal nest in period 1 and nl 0 if the con sumer stays with the par ents in period 1 and leaves the paren tal nest one year later let the time pref er ence dis count fac tor be β and the gross inter est rate be r and assume that the con sumer can freely lend and bor row at that inter est rate after leav ing the paren tal home the opti mi za tion prob lem then is max c 1 c 2 c 3 nl β t 1 3 ∑ t 1 u t which is sub ject to the fol low ing c 0 c c 1 c if nl 0 c 1 y 1 a 1 if nl 1 c 2 y 2 a 2 if nl 0 c 2 y 2 a 2 ra 1 if nl 1 c 3 y 3 ra 2 if nl 0 the con sumer leaves the paren tal home in period 1 if their life time util ity is higher when nl 1 but oth er wise leaves in period 2 the issue is whether nl 1 is more likely if c is high or low for a given income at periods 1 2 and 3 we can work out the ana lyt i cal solu tion if we adopt the cara spec i f ca tion as in eq and use it to cal cu late and com pare the util ity of the nestleav ing and homestay ing strat e gies it is worth stressing that the way the con straints are writ ten the cohabiting child passes along the entire period 1 income to the par ents in exchange for enjoying a given con sump tion level c this model pre dicts that for a given com mon income pro fle golden nest indi vid u als are less likely to move out in period 1 than the less for tu nate in figure 4 we show the util ity gain asso ci ated with nest leav ing when income takes val ues of 05 in period 1 1 in period 2 and 15 in period 3 the inter est rate and the time pref er ence param e ter are 2 hence r 102 β 1 102 the abso lute risk aver sion param e ter θ is set equal to 2 we con sider how the util ity gain changes as a func tion of c and the force of hab its the hab its param e ter γ is allowed to vary between 0 and 09 we see that the util ity gain from nest leav ing is a decreas ing func tion of both c and γ the higher the con sump tion at the paren tal home and the stron ger the habit the less appeal ing nest leav ing becomes the util ity gain from nest leav ing is always pos i tive for the low est val ues of c imply ing that indi vid u als pre fer leav ing the paren tal nest in period 1 if their stan dard of liv ing in the paren tal home is suf f ciently low however there is a c high enough that nest leav ing is delayed in the model with out hab its this thresh old is c 075 when hab its are par tic u larly strong indi vid u als pre fer stay ing in the paren tal home even if c is as low as 065 we obtain sim i lar results for a less steeply ascend ing income path in that case nest leav ing is more fre quently the pre ferred option but the util ity gain shown in figure 4 is still a decreas ing func tion of c and γ we fnd that changes of the riskaver sion param e ter and the inter est are of lit tle con se quence for the nestleav ing deci sion our model ignores bequests par ents can stra te gi cally use bequests to induce their chil dren to post pone the nest leav ing this fea ture of the model should strengthen its main pre dic tion that chil dren who grow up in a golden nest leave the paren tal home at later ages it also ignores the pos si bil ity that the util ity func tion depends on liv ing arrange ments however if pref er ences change upon nest leav ing the same way across indi vid u als our model pre dic tion should be unaf fected 9 9 for instance fernandes et al devel oped a sim i lar but more com plex model that con sid ers the role of income inse cu rity as well as paren tal util ity and altru ism conclusions we used data cov er ing 28 euro pean countries plus israel to show empir i cally that indi vid u als who grew up in a golden nest leave the paren tal home later this result is remark able for two rea sons first it con tra dicts the com monly held view that the nestleav ing deci sion is mostly deter mined by cul tural fac tors second it con tra dicts the typ i cal hypoth e sis in the eco nom ics lit er a ture that cap i tal and hous ing mar ket imper fec tions explain why young peo ple fnd it hard to leave the paren tal home if cul ture were the driv ing force the ses gra di ent should not be sim i lar across countries that mark edly dif fer in their cul tural back ground if lim ited access to credit or cheap hous ing were the key issue we would expect poorer chil dren to delay nest leav ing not richer ones we then solved a threeperiod intertemporal opti mi za tion model to dem on strate the con di tions under which this behav ior is con sis tent with stan dard assump tions on pref er ences and resources our key result is that a stan dard life cycle model with out bor row ing con straints pre dicts this type of behav ior if earn ings increase with age and the stan dard of liv ing in the paren tal home is higher than the income earned early in the life cycle we also fnd that habitforming pref er ences rein force the delaying effect of a golden nest on nest leav ing because these pref er ences make drops in the stan dard of liv ing par tic u larly unat trac tive to the con sumer an impli ca tion of our results is that to the extent that early nest leav ing has pos i tive lon gerrun con se quences on chil drens eco nomic wel fare the ear lier nest leav ing by chil dren of lowses fam i lies may con trib ute to increases in inter gen er a tional mobil ity in income and wealth to the extent that late nest leav ing is explained in terms of pref er ences and eco nomic resources a laissezfaire atti tude is jus ti fed in purely eco nomic terms if policymakers believe that late nest leav ing should be dis cour aged they can use fs cal mea sures to increase bet teroff young adults incomes or decrease their par ents income examples could be a reduced or even neg a tive earn ings tax a tion for young indi vid u als liv ing inde pen dently accom pa nied by the pro gres sive tax a tion of total house hold income however these pol i cies would favor at least some of those who are bet ter off in a life time sense and may increase wealth inequal ity ■

the online ver sion of this arti cle doi org 10 1215 00703370 9940728 con tains sup ple men tary mate rial

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introduction a lthough the family planning 2020 global movement has focused attention on improving access to modern contraception among the worlds poorest women evidence suggests this goal is still far from reality 1 as programs continue to expand access to family planning information services and products it is critical to undertake these efforts with an equity lens ensuring that regardless of socioeconomic status all women and couples can use the method that meets their needs in particular for women and couples to make an informed choice programs need to provide information about the benefits of longacting and permanent methods as well as access to those methodseither directly or through referrals lapms comprise the longacting and reversible methods of iuds and implants as well as the permanent methods of tubal ligation and vasectomy benefits of lapms include convenience effectiveness costeffectiveness and potential health benefits 2 3 4 but overall use of lapms is still low in developing countries regional lapm contraceptive prevalence rates average 42 and 219 in subsaharan africa and latin america respectively 5 many studies have demonstrated that wealth is positively associated with modern contraceptive use 6 7 8 9 however it is unclear whether wealthier women are more likely than poor women to use lapms than shortacting methods to our knowledge only 3 studies have explored this issue 71011 these studies suggest that wealth and lapm use may be positively associated in developing countries creanga et al 7 conducted multivariate analysis of demographic and health survey data spanning 13 countries in subsaharan africa and noted that use of longacting contraceptive methods was more common among women in the wealthiest quintile than women in the poorest wealth quintile however by focusing only on the top and bottom wealth quintiles that analysis left unanswered questions about access for the middle wealth quintiles using bivariate analysis ross and agwanda 10 explored the use of modern methods in particular injectables by wealth quintiles using data from dhs and the united nations development programme in 28 countries14 in eastern and southern africa and 14 in west and central africa the study found that women from wealthier households were more likely to be using pills injectables condoms or female sterilization than women from poorer households although the results were informative they do not provide insights into how household wealth is associated with use of one type of method over the others similarly fotso et al 11 analyzed dhs data from kenya using multivariate regression and found that wealthier women were more likely to use lapms than poorer women a disparity that increased from 2003 through 20082009 our analysis builds on these prior studies by conducting multivariate regression analysis in 30 countries in 3 regions to explore the relationship between household wealth and the type of contraceptive method used multivariate analysis allows us to correct for potential confounders that are correlated with wealth and that may affect the choice between lapms and shortacting methods to our knowledge this is the first study to explore the relationship between wealth and type of method across all wealth quintiles for many countries and different regions using multivariate regression techniques to control for confounding factors reasons that poor women may be less likely to use lapms could include barriers that programs need to address such as financial costs geographic barriers medical and legal restrictions 12 13 14 15 provider bias and misinformation social and cultural barriers 16 or simply different preferences this paper cannot identify the reasons for nonuse of lapms given data limitations rather the purpose of this article is to determine whether a clear relationship exists between wealth and use of longacting versus shortacting methods of contraception substantiating such a relationship allows the family planning community to advocate solutions to close this gap and find ways to remove barriers to lapm use among poor women through formative andor intervention research making this information available at the country level also helps countries understand whether this is a possible equity issue that needs to be resolved however it should be noted that proportions of women who are in need of lapms may be different by country because age structures and proportions of women wanting to limit childbearing may differ across countries data and methods our analysis used data from the dhs which are household surveys that are nationally representative and internationally comparable focusing primarily on reproductive health fertility and maternal and child health indicators we used the most recent dhs data from 30 countries across 3 regions 15 in subsaharan africa 9 in asia and the middle east and 6 in latin america and the caribbean the surveys were conducted between 2006 and 2013 our final sample of countries was selected according to the following criteria first the most recent dhs was conducted in 2006 or later second of the relevant sample of women of reproductive age who were not currently pregnant and who had ever been sexually active at least 10 reported currently using a modern contraceptive method third the final sample for the country had to have at least 100 users of either lapms or shortacting methods among the relevant sample of women to assess the prevalence rates of traditional and modern contraception by type of method we analyzed the sample of women of reproductive age who had ever been sexually active and who reported not being pregnant at the time of the interview table 2 displays the proportion of those women who reported using either no method traditional methods shortacting methods or lapms for each country most countries in subsaharan africa had low use of lapms ranging from 1 in cameroon and nigeria to 7 in kenya namibia and rwanda and up to 11 in malawi some countries in asia and latin america displayed much higher prevalence ratesfrom 27 in jordan and nepal to 39 in egypt and the dominican republic to over 40 in india and colombia for the multivariate analysis in this paper we examined the subgroup of women who in addition to being of reproductive age sexually active and not currently pregnant also reported using a modern method of contraception at the time of the interview in some countries in north africa the middle east and asia the questions regarding access to and use of modern contraception were asked only to married women table 3 presents descriptive statistics for each study sample in the 30 countries average age average number of children alive at time of the interview education urbanrural residence and distribution of the use of modern methods by type it also displays the numbers of observations of women who have all these requisites per survey that were considered for our analysis variables our outcome of interest was a dichotomous variable that was equal to one if the woman reported using a lapm and zero if she reported using a shortacting method our main independent variable was household wealth a variable that is included in the dhs datasets as a composite score based on asset ownership and quality of housing all surveyed households are ranked by index score and accordingly assigned to 1 of 5 wealth quintiles 17 this method of categorizing households based on wealth quintiles has been shown consistent with other wealth rankings eg based on consumption expenditure aggregates especially when other socioeconomic characteristics are taken into account 1819 in the multivariate analysis we represented this wealth variable as a vector of 5 dummy variables with the poorest quintile serving as the reference group other control variables included age in linear and quadratic form number of living children in linear and quadratic form education as a vector of dummy variables representing levels of education completed including none elementary secondary and tertiary education a vector of dummy variables for employment status and type of occupation of the head of the household a dummy variable for marital status equal to one for women who were married or living in union and zero otherwise urbanrural residence we included this vector of controls in order to isolate more precisely the relationship between use of lapms versus shortacting methods and wealth as a proxy for disposable income age and education for example are variables that are correlated with both wealth and use of either type of method controlling for them is equivalent to exploring the nature of the relationship between wealth and use of lapms within women of the same age or same level of education although some of these controls are highly correlated in order to improve the precision of our estimates and reduce the potential for omitted variable bias all of them were included as controls simultaneously we hypothesized that most countries would show a positive association between wealth and use of lapms it was expected that this could occur in the form of a positive linear relationship across all wealth quintiles or in the form of a nonlinear relationship ie just for the highest quintiles a negative relationship would mean that wealthier women would be less likely to use lapms than poorer women analytical methods first we examined the unadjusted relationship between our outcome of interest and our main independent variable separately for the 30 countries in our final sample second we ran multivariate logistic regressions for each country in order to control for specific individual and household characteristics that can confound the relationship between wealth and contraceptive method of choice these control variables were age number of living children educational attainment employment status and type of occupation of head of household marital status and urbanrural residence the multivariate analysis was performed using logistic regression models to yield coefficient estimates displayed as odds ratios these ratios represent the odds of an individual using a lapm over the odds of using a shortacting method we used the withincountry weighting variables specified by each countryspecific dhs occasionally a country presented strata with a single sampling unit in our regressions those strata were treated as certainty sampling units 20 results unadjusted analysis the unadjusted relationship between wealth and use of lapms among modern method users varied across countries the complement of each proportion reported in table 4 is by definition the proportion of women using shortacting methods in burundi for example among the sampled women in the poorest quintile 22 used lapms and the remaining 78 used shortacting methods overall in 17 of the 30 countries a greater proportion of women in the wealthiest quintile used lapms compared with women in the poorest quintile conversely of course shortacting methods were used by a greater proportion of poorer women than wealthier women this positive relationship between wealth and use of lapms was the dominant pattern in each region observed in half to twothirds of the countries sampled 10 of the 15 african countries 5 of the 9 asianmiddle eastern countries and 3 of the 6 latin americancaribbean countries there were many exceptions to this pattern however four countriesbangladesh haiti india and pakistanexhibited a clearly negative relationship lapm use was far more common among poorer women than among wealthier women for another 4 countries the relationship resembled an inverted ushape with lapm use higher in the middle wealth quintiles and lower in both the poorest and the wealthiest quintiles in burundi and senegal the relationship resembled a ushape with lapm use more likely in both the poorest and the wealthiest quintiles and lower in the middle quintiles however no large differences were observed in the proportions across all in most countries wealthier women were more likely to use lapms than poorer women quintiles finally in cameroon colombia and guyana there appeared to be no relationship between wealth and type of method used multivariate analysis we used multivariate logistic regression to control for a vector of potentially confounding covariates age number of living children education employmentoccupation marital status and urbanrural residence table 5 shows the adjusted odds ratios from the multivariate regressions organized by region the 30 countries exhibited 1 of 4 patterns a consistently positive statistically significant relationship across all 5 wealth quintiles such that wealthier women were more likely to use lapms and women in the lowest wealth quintiles were more likely to use shortacting methods a positive association between wealth and lapm use only when comparing the top 1 or 2 wealthiest quintiles with the poorest quintile and no significant difference in lapm use between the lower wealth quintiles and the poorest quintile that is women from the lowest 2 or 3 quintiles showed no systematic preference for lapms or shortacting methods and the wealth effect was apparent only in the highest wealth quintiles no significant differences in lapm use or a significant difference only when comparing the lower or middle quintiles with the poorest quintile in these countries wealth did not appear to be associated positively or negatively with lapm use a significant negative association between wealth and lapm use such that wealthier women were more likely to use shortacting methods and poorer women were more likely to use lapms these patterns varied by region in subsaharan africa as noted in the unadjusted analysis 10 of the 15 countries analyzed showed statistically significant and positive relationships overall between wealth and lapm use in 3 of these 10 countries women from almost all upper quintiles were significantly more likely to use lapms than women in the poorest quintile in 6 of the 10 countries a significant relationship was found only when comparing the top 1 or 2 wealth quintiles with the poorest quintile tanzania showed a significant positive association only when comparing the second and fourth quintiles in the other 5 sampled subsaharan african countries no statistically significant relationship was found when comparing the poorest quintile with any other quintile in asia and the middle east a positive and statistically significant relationship between wealth and lapm use was noted in 5 countries cambodia egypt indonesia jordan and nepal in 3 of those countriescambodia indonesia and jordanthe relationship was significant only for women in the wealthiest quintile in 2 other countriesbangladesh and indiaa significant negative relationship was found in those countries as discussed below poorer women were more likely than wealthier women to use lapms rather than shortacting methods no association was found for pakistan or the philippines finally in latin america and the caribbean 5 of the 6 countries showed positive and statistically significant associations between wealth and lapm use mostly across all wealth quintiles haiti was the exceptionalthough the association was not statistically significant the average odds ratio was around 054 suggesting that women from the lowest quintile may be more likely than wealthier women to use lapms than shortacting methods as in bangladesh and india there was wide variation in the magnitude of the outcome differences some countries showed a markedly larger likelihood of lapm use for women from the wealthiest quintile four countriesbolivia lesotho namibia and zambiahad odds ratios greater than 3 when comparing outcomes between the wealthiest quintile and the poorest quintile showing the strongest association between wealth and lapm use discussion using recent data from 30 countries in 3 regions we examined patterns of use of lapms and shortacting methods in relation to household wealth our analyses showed a general pattern of greater lapm use by wealthier women 20 of the 30 countries showed some pattern of positive and statistically significant association between wealth and lapm use however for 10 of those 20 countries this pattern was limited to a comparison between the wealthiest 1 or 2 quintiles and the poorest quintile there was no significant difference in bangladesh and india poorer women were more likely than wealthier women to use lapms than shortacting methods between usage by women from the poorest households and women from middleincome households these findings suggest that in many countries the income threshold is highfor reasons that remain to be explored the remaining 10 countries analyzed demonstrated 2 different patterns no significant relationship was found between wealth and type of method used in 8 countries burundi cameroon ethiopia madagascar and senegal pakistan and the philippines and haiti the other pattern was a significant inverse relationship between wealth and lapm use in bangladesh and india poorer women were more likely to use lapms than wealthier women and wealthier women were more likely to use shortacting methods than poorer women this inverse pattern may reflect a different policy environment in these countries where supplyside and demandside incentives reinforced by community mobilization contribute to high uptake of lapms among the poor in bangladesh for example lapm service delivery has been prioritized by the government and is backed with a large budget including funds for client compensation and provider fees 21 in india female sterilization is the leading method of contraception accounting for twothirds of all current contraceptive use and about threequarters of all modern method use 22 it is provided free of charge in the public sector 23 and has a long history of government promotion as the primary method of family planning 24 although the indian government ceased to announce national sterilization targets in 1996 there is some evidence that targets and reimbursements to cover costs such as travel expenses are still used to encourage female sterilization 2526 while our study did not analyze use of specific lapms by wealth we can assume the patterns are generally similar to regional patterns among all contraceptive users for example in latin america and the caribbean out of a modern contraceptive prevalence rate of 581 almost onethird is from lapms with a strong presence of female sterilization and to a lesser extent iuds 27 in countries from asia the middle east and north africa where the mcpr is 517 lapms contribute 143 to that mcpr with 8 of women using iuds and approximately 5 using sterilization in countries from subsaharan africa mcpr is 265 and overall lapm use is low at less than 5 with less than 2 of women using implants and less than 2 using sterilization the positive relationship between wealth and lapm use is an issue of concern as it may indicate that there is inequity in access to lapms in many developing countries these differentials may be due to several reasons and have different remedies poor women may be less likely to use lapms due to financial barriers which could be addressed by voucher programs that subsidize the costs of lapm services similarly contractingout through ngos could improve access to these methods so that women do not have to pay full price through private providers and facilities geographic barriers may be an issue for poor women which is more difficult to address this may require more concerted efforts to provide lapms through highquality mobile outreach services in poor areas 28 in addition the expansion of social franchising programs can remove geographic barriers by training providers in hardtoreach areas in the provision of lapms while ensuring they have needed supplies and quality standards 2930 lack of information among women andor their spouses may lead couples to be less likely to use lapms addressing this issue would require a concerted effort by both the public and the private sectors so that messages focus on the benefits of these methods rather than on the specific type of provider for example in jordan a privatesector health project funded by the united states agency for international development supported a behavior change communication campaign that focused on the benefits of using iuds the project demonstrated changes in knowledge attitudes and intention to use iuds without focusing on the source of the a medical intern in bangladesh inserts a contraceptive implant in a clients arm under supervision while other interns watch and learn inequity in access to lapms may be an issue in many developing countries method 31 addressing the problem of lack of information about lapms also requires that community health workers who do not provide the methods be conversant in the benefits and referral systems so that women and couples can access the full range of methods that helps them achieve their reproductive goals it also may be possible that poorer women simply have different preferences followup formative research and intervention testing is required to disentangle the reasons we find this strong association across a large number of countries limitations the analysis has several limitations first the dhs data do not provide specifics such as location and proximity to services which influence access to methods these characteristics may be correlated with both household wealth and contraceptive choice second for the purposes of this analysis we have grouped all types of lapms together due to the issue of sample size however we might find differing patterns for longacting reversible methods versus permanent methods third in a few countries the use of any modern method was low across all wealth quintiles but especially in the lowest wealth quintiles in those countries we found no statistical significance across the key wealth coefficients but that may be due to small sample size of women from those quintiles using modern methods fourth this analysis provides a snapshot of current behavior it does not capture change over time despite its limitations this paper demonstrates a strong positive relationship between wealth and lapm use in many developing countries that deserves further exploration conclusion in most developing countries wealthier women are more likely than poorer women to use longacting and permanent methods of contraception than shortacting methods notable exceptions are bangladesh india and possibly haiti where poorer women are more likely to use longacting and permanent methods than wealthier women perhaps reflecting a different policy environment than in other countries competing interests none declared

in general across the developing world wealthier women are more likely than poorer women to use longacting and permanent methods of contraception instead of shortacting methods exceptions are bangladesh india and possibly haiti

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introduction the need to combine active employment and parenthood is a reality for most parents in sweden as the fraction of women in the work force is high among women aged 2064 years 76 were in active employment in year 2010 which places sweden as one of the countries in the eu with the highest employment rate 1 the mean employment rate in the eu was approximately 60 the employment rate among swedish women has increased from 68 in year 1976 to 72 in year 2004 the difference in employment rate between men and women has during the same period decreased from a 20 lower employment rate among women in 1976 to only 3 lower in year 2004 2 even higher employment rates are found among swedish parents in 2008 83 of all children aged 017 years had an employed mother and 93 had an employed father 3 parttime work was more common among mothers than among fathers major reasons for the high employment rates among mothers are the relatively generous parents insurance and the welldeveloped day care system together these enable both mothers and fathers to continue their employment after the birth of their children the parents insurance means that either parent can stay home from work while getting paid up to 80 of their salary during a total of 480 fulllength days in the 8 years after the child is born this insurance is not exclusive for mothers with the original article working parents stress and health 693 exception of 60 days that are bound to each parent the parents are free to divide the days between them as best they see fit however although the fathers use of parental leave has increased during recent years the majority is still used by mothers and only 24 of the parental leave was used by fathers in 2011 4 when both parents return to work the child is guaranteed a place in municipal day care during the parents working hours the fee per child for participation in such day care is fixed by law to be no higher than 3 of the parents combined brut income moreover from the age of 3 all children are allowed 525 hours per year of free child care at the same municipal day care once both parents have returned to work either parent is allowed to stay home from work when the child is sick with up to 80 of salary payment also until the child turns 12 years both parents are allowed to take unpaid parttime leave from work without losing their right to go back to fulltime work whenever they choose the insurances described above apply to all swedish citizens and are likely to enable the combination of parenthood and employment still this combination may be challenging for many men and women previous studies show that even in couples where both the man and woman work full time it is still often the woman who takes on the largest responsibility for children and household work 5 also women report more work overload stress and conflict between work and family demands than men these outcomes are found to increase significantly with the number of children at home and peak between the ages of 35 and 39 6 an international study that compared the experience of inference between paid work and household demands among women in five different countries showed that the swedish women reported the highest level of workfamily conflict in the examined groups this was supposed to be at least partly because swedish women more often had more qualified and demanding jobs compared with women in other countries 7 international studies have shown that high levels of conflict between paid work and household demands socalled workfamily conflict are associated with increased sick leave and decreased mental wellbeing for both men and women 89 overtime work change in number of work hours and commuting time have been related to higher levels of workhome interference while compensation for overtime work familiarity with work roster ability to take an occasional day off and a decrease in work hours at own request were associated with less workhome interference 1011 however workfamily conflict may not necessarily have the same causes in men and women 11 also the effect of workfamily interference and work place experiences on health wellbeing and parenthood seem to differ between men and women a swedish study showed that employed womens subjective symptom report was affected by the interaction between working conditions and household duties whereas the mens health appeared to be more affected by long working hours 12 womens work experience has also been shown to affect their parenting after controlling for occupational status and general wellbeing mothers who reported a more negative interpersonal atmosphere at work showed decreases in positive parenting and increases in negative personal parenting over time the fathers work experiences seemed however to be unrelated to their parenting 13 although previous studies have explored associations between work place conditions and workfamily interference and between workfamily interference and health not much focus have been on specific work place factors and the association with various health outcomes among working parents with small children knowing more about which work place factors are associated with better or worse health could help employers to form a work environment that provides optimal conditions to maintain or increase subjective health wellbeing and work engagement among working parents a large and increasing group in many societies the aim of this study was to explore possible associations between different work factors and benefits and a range of outcome variables such as subjective stress symptom report wellbeing workrelated fatigue work engagement and workfamily conflict among working mothers and fathers with small children a further aim was to explore if there were any gender difference in the associations between work place factors and the outcome variables methods study sample and procedure the study population was parents whose youngest child was either 2 or 7 years old to locate these we used the perinatal revision south which is a medical birth registry that covers all births in swedish southern healthcare region since only mothers are included in the registry we sent both questionnaires to her asking her to give one of them to the childs father providing that they were cohabitating or had joint custody the selection frame consisted of all women localised through prs who fulfilled the primary inclusion criteria with a child aged either 2 or 7 years and no registered deliveries since then through a computerbased randomisation process 2000 mothers of 2yearold children and 2000 mothers of 7yearold children were randomly selected from the selection frame population of these 85 were excluded since the family had emigrated had protected identity or either the child or mother had died invitations for both parents to take part in the study was sent to the remaining 3915 mothers inclusion and exclusion criteria were stated in the letters accompanying the two questionnaires they stated that both parents had to work at least 50 of full time to be eligible for the study and that the woman should not be pregnant or have given birth to any children during the last 2 years furthermore the parents should be either cohabitating or have joint custody and none of them should suffer from any serious disease or chronic illness we have no data on the number of nonrespondents who did not respond because they violated one or more of the inclusion and exclusion criteria however a record check showed that at the time of the mailing 879 children had parents where either the mother or father or both were not in current labour work moreover among those who responded to the study 22 mothers were excluded since they were currently pregnant and 35 fathers were excluded since the parents did not have joint custody thus the actual net study sample consisted of 3015 women and 3001 men resulting in a total of 6016 persons of the 6016 parents in the net sample 1552 responded to the survey of these 962 were women and 590 men this corresponds to an overall response rate of 26 for mothers 32 for fathers 20 measures as measures of exposure we considered the presence or absence of concrete and subjective work place conditions in two dimensions flexibility and benefits furthermore we assessed factors related to the experienced general work place attitude towards parenthood to measure outcome variables a number of wellestablished instruments for measures of subjective wellbeing workfamily conflict and work stress and engagement were used these are described in detail below the questionnaire also contained information regarding type of work work time work position middlelevel manager educational level and household income subjective wellbeing subjective wellbeing was assessed by tools for measuring global stress 14 physicalpsychosomatic symptoms selfrated health and workrelated fatigue pss contains 14 questions regarding the experience of different aspects of global stress during the last month 14 each question is rated from never to very often the mean score of the 14 items was used in the analyses hence with a possible score range from 0 to 4 chronbachs alpha for the scale was 085 the lshc is an inventory assessing the intensity of 13 common health complaints experienced during the last 30 days these include headache dizziness forgetfulness back pain neckshoulder pain and stomach pain the lshc has been developed by the department of occupational and environmental medicine at the lund university hospital and is rather similar to the uhishcscale 17 for each health complaint the parent was to indicate the frequency during the preceding month from 1 to 5 in the present study a global measure representing the mean score of all items was used chronbachs alpha for the scale was 092 srh7 is a single item asking about the subjective perception of current physical and mental wellbeing measured from 1 to 7 15 sofi20 measures workrelated fatigue from a multidimensional perspective including five different dimensions of fatigue lack of energy lack of motivation physical exertion physical discomfort and sleepiness 16 each item was assessed for the end of a typical work day and rated from not at all to to a very high extent in the present study a global measure of the mean score of the 20 items was used chronbachs alpha for the scale was 094 work stress and engagement work stress and engagement was assessed using the utrecht work engagement scale 18 and qps nordic36 19 working parents stress and health 695 uwes is a 17item instrument measuring work engagement including the three subscales vigour dedication and absorption the mean score of each subscale was analysed in the present study resulting in three subscale scores with a total score that range between 0 and 6 chronbachs alpha for the subscale was for vigour 077 dedication 090 and absorption 080 qps nordic36 is the short version of the qps nordic 19 this instrument has been developed in sweden denmark finland and norway it contains a wide variety of dimensions such as workrelated demands and control role expectations social interaction leadership group work organisational climate several of these dimensions correspond to our independent work place factors and hence we only used the workrelated demands and control items as dependent variables in our analyses as a measure of workrelated stress workfamily conflict we used an eightitem inventory covering both timeand strainbased conflict between work and family two different dimensions of workfamily interference were measured worktofamily conflict ie spillover effects from work on family life and familytowork conflict ie spillover from effects from family obligation and demands on working life with four items for each dimension 20 response alternatives ranged from do not at all agree to agree completely the mean score of the four items for each dimension was used in the present study resulting in two subscores with a possible score range from 15 work place factors the participants were asked to indicate how they experienced the general attitude towards parenthood among managers and colleagues the response alternatives were positive towards both mothers and fathers more positive towards mothers than fathers more positive towards fathers than mothers negative towards both mothers and fathers neutral no specific attitude i dont know and not applicable the response alternative positive towards both mothers and fathers was categorised as positive attitude whereas the others were categorised as negative or neutral attitude the participants were also asked to indicate the presence or absence of 14 different work place conditions as listed below the presence of or access to the condition or benefit was categorised as present whether or not the respondent reported that they utilised it or not the 14 different conditions or benefits were together with the two attitude variables categorised into three different dimensions flexibility benefits and attitude internal missing on the individual items varied between 06 and 15 the categorisation of the different conditions is presented in table i statistical analysis the statistical analyses aimed to explore possible associations between different work place factors and subjective measures of stress and wellbeing all analyses were potential effect modification from gender was assessed by including the interaction term group × gender if the interaction showed a significant effect genderstratified analyses were performed in order to further evaluate the differences in the effect between men and women in these cases mean differences with accompanying 95 confidence intervals are presented for men and women respectively all pvalues ≤005 were considered significant ethics the study was approved by the ethics committee at lund university and conformed to the provision of the declaration of helsinkki results flexibility with the exception of having the possibility to take short breaks for urgent matters the flexibility dimension did not have any impact on the parents subjective wellbeing as indicated by pss shc srh and sofi20 however several of the factors in the flexibility dimension seemed to have a beneficial effect although not consistently large on workrelated control and engagement also some of them such as home work seemed to be associated with higher levels of workfamily conflict while others such as the possibility to take a break or leave the work place when needed were associated with lower levels of worktofamily spillover home work and flexible or unregulated work time was associated with higher workrelated demands for all three subscales of uwes there were a significant interaction between unregulated work hours and gender indicating different impacts for men and women stratified analyses showed that the significant effect was found among men only among women there were no significant association between unregulated work hours and work engagement significant interaction effects and subsequent stratified analyses showed that also regarding home work both for hours and full day the association with worktofamily spillover was significant only among men home work during days however was associated with larger increase in workrelated control among women than among men there was also a significant interaction effect between the possibility to take a break when needed and workrelated control stratified analyses showed that although there was a significant effect for both men and women the effect was even stronger among men benefits there were only very few associations between benefits and subjective wellbeing and workfamily conflict the relationship between benefits and work stress and engagement was slightly more evident than for the other two outcome categories but the effect was not consistent over the different factors or outcomes the majority of the findings were for qps control where some of the benefits were found to have a beneficial effect although there was no significant main effect of exercise time on worktofamily spillover there was a significant interaction effect with gender however stratified analyses showed that even though women who had the possibility to exercise during work time tended to have lower levels of worktofamily spillover the effect was not significant among either men or women also for child care subsidisation and work dedication there were no significant main effects however among men the presence of child care subsidisation was associated with significantly higher levels of work dedication attitude the beneficial impact of experienced work place attitude towards parenthood was consistent for all factors of the dimension and all outcome variables the association was strongest for subjective wellbeing where there were statistically significant relationships between all attitude factors and almost all outcome measures with the exception of meeting policy significant interaction effects and subsequent stratified analyses showed that the beneficial effect of a positive attitude among managers on perceived stress subjective health complaints and selfrated health and the effect of positive attitude among both managers and colleagues on workrelated fatigue were even stronger among women than among men indeed for some of these variables the beneficial effect was significant only among women regarding a positive attitude among colleagues the reduction in workrelated fatigue was significant among women only significantly lower subjective health complaints and higher selfrated health were found among women who experienced a positive attitude among their managers while there was no corresponding significant effect among men a significant interaction effect and its subsequent stratified analyses showed that the beneficial effect of having a clear back up during absence on worktofamily spillover was even stronger among men than among women although there were no significant main effect on familytowork spillover the interaction effect and subsequent stratified analyses showed that women who had the possibility to bring children to work had significantly lower levels compared to women who did not have this possibility stratified analyses also showed that the effect on workrelated control was slightly stronger among women than among men discussion the results showed that work place factors related to flexibility and especially among women attitude to parenthood appear to have the strongest effect on working parents subjective stress and wellbeing while benefits appear to have less impact except regarding factors related to attitudes at the work place most association between work place factors and outcome measures appeared to be similar among men and women however the results should be interpreted in the light of some methodological aspects and limitations methods although we sometimes present the results in terms of effects of different work place conditions the cross sectional design of the study makes it impossible to establish evident causality between the examined factors we analyse associations between variables and must be aware that part of the effect may come from a reversed causality ie the report of work place conditions may to some extent be affected by the individuals general wellbeing this may apply more to the subjective work place factors than to objective or concrete conditions and benefits it is also worth to note that it is difficult to separate completely between work place factors and specific occupations since some conditions related to for example flexibility are much more prevalent in some occupational categories and this may be linked to socioeconomic factors known to be associated with wellbeing although we adjust for some socioeconomic factors such as education and work position there may still be some influence from unmeasured socioeconomic inequalities related to some of the conditions the categorisation of work place conditions aims to facilitate the presentation and interpretation of the results by collapsing the many different conditions and benefits into more general themes this categorisation is arbitrary and based on a subjective evaluation of common themes within the different conditions however it is noteworthy that it facilitated to recognise patterns indicating that factors relating to attitudes and office social climate are of high importance for the wellbeing of parents with small children a major limitation of the present study is the low response rate despite repeated reminders the response rate did not exceed 26 slightly higher for women than for men this is difficult to explain since the aim with the study was supposed to be experienced as important and relevant for the invited participants and hence entice to participation even though we were aware that we invited a group that may be under much stress and experience time restrictions although through a later record check we excluded persons who were not in active employment at the time for the survey and hence were not included in the target population some of the other exclusion criteria were based on the parents own judgement eg regarding pregnancy and chronic diseases hence the true net sample may be smaller than we report and hence the response rate would be slightly higher still the low response rate raises the question about whether the study sample can be regarded as representative for the target population with respect to their score on the pss scale the men and women included in the present study were comparable to other healthy populations investigated in recent studies 2122 hence there does not seem to be a selection of particularly stressed or nonstressed individuals however more important is the fact that the primary aim with the present study was to explore associations between different work place conditions and wellbeing and there are no reasons to believe that the sample should not be representative regarding these associations results the factors within the attitude dimension show the strongest associations with health outcomes a positive attitude from colleagues and managers is related to a positive outcome in all examined variables ie lower stress fatigue subjective health complaints and experienced workfamily conflict as well as higher work engagement and general selfrated health this is in accordance with the parents own perception of which factors are most important for maintaining a fruitful balance between work and family where understanding from managers and colleagues was ranked as most important followed by a parent friendly policy at the company 23 in the present study the beneficial effects of positive attitude and understanding from the manager were even stronger for women than for men this may indicate that the concern about social support and social interaction is more important for women indeed a previous report showed that women to a higher degree than men worried about letting managers and colleagues down when they were absent due to a sick child 23 this may partly be because women more often stay home when the child is sick and hence are more likely to experience larger effects of the absence however it may also reflect more concern about the social responsibilities and social interaction at work previous studies have indicated that relationships at work are of importance for especially women a recent review regarding female physicians career satisfaction showed the female physicians career satisfaction was associated with perceived relationships with colleagues as well as patients 24 another study on female urologists showed that the major reason for leaving academics was lack of mentoring rather than family issues 25 and although men and women have been shown to value the same aspects of work they seem to rank them differently women have ranked factors such as friends and relationships communication fairness and equity and teams and collaboration significantly higher than men 26 a clear structure for back up during absence also appears to be an important factor for the subjective wellbeing and stress among working parents this might of course be interpreted as a beneficial impact on stress from knowing that the work load is not increasing during absence however it may also be a reflection of the nature of the job more occupations within the public sector such as many of the traditional female occupations eg within health care and education are better suited for a system with standins or reflect an attitude at the work place and an awareness about potential needs and an attempt to reduce the stress for both the absent employee and the colleagues the possibility to bring the child to work when needed had an evident effect on most outcomes several interpretations of this finding are possible it could be the manifest possibility that has beneficial effects on the wellbeing however this possibility may also be a proxy for a more general attitude within the company including understanding for potential needs and an openness to alternative solutions it may also be an indication of a flexible work situation interestingly among women the possibility to bring your child to work tended to be associated with a lower familytowork spillover this indicates that the possibility could decrease the spillover from family duties such as absence due to child care by allowing a combination of simultaneous child care and work however a previous report showed that as many as one in four of both fathers and mothers thought that the possibility to bring child to work may instead increase the stress probably by signalling that one is expected to work even when one needs or would like to stay at home with a child 23 next after understanding from colleagues and managers different flexibility factors were previously ranked by the parents as most important for maintaining a fruitful balance between work and family life 23 it was therefore not surprising that several of the flexibility factors were also significantly associated with beneficial outcomes in the present study flexible andor unregulated work hours was associated with both higher workrelated demands and higher workrelated control which indicates an active work situation in contrast to a strained work situation where the high demands are combined with a low control while high demands in combination with low control has been considered as a risk factor for both physical and mental ill health effects 2728 an active work situation is considered much more positive 29 also the unregulated work time in particular was associated with high work engagement vigour dedication and absorption however part of these associations may be attributable to that unregulated work time is generally associated with more skilled occupations although we controlled for work position and educational level there may still be some influence from differences in occupations thus part of the beneficial outcomes associated with high control and work engagement may be attributable to the occupation rather than the unregulated work time also stratified analyses showed that the positive association between unregulated work hours and work engagement was evident for men only still it is worth to note that the unregulated work times was not found to be associated with any negative outcomes among either men or women which could have been expected due to lack of clear borders and regulation of the work time this could in turn have let the work spillover too much on other parts in life causing negative outcomes however we did not find any evidence for this for both men and women the possibility to work from home was associated with higher work engagement and higher workrelated control however it was also associated with higher levels of both worktofamily spillover and familytowork spillover especially among men this is partly in accordance with a previous american study which examined work place factors and workhome interference among women 1 year after childbirth this study showed that some flexibility factors such as the ability to take work home were associated with increased hometowork spillover but not with worktohome spillover 30 in our study the positive association with workrelated control was stronger among women hence it appears that the possibility to work from home is more beneficial for women still despite the adjustment for work position and educational level the possibility to work from home may be associated with certain occupations that are individually associated with higher work engagement and control most parents reported that they had the opportunity to take a short break and many also to leave work on short notice if needed this possibility was associated with higher workrelated control and a lower level of worktofamily spillover it was also associated with lower levels of perceived stress and workrelated fatigue not having the possibility to take such a short break may depend on an extremely high work load but is probably more often due to very rigid and inflexible occupations however in many occupations the possibility to take breaks may vary during the work day depending on the acute situation for example a surgeon will not be able to take a break during surgery while during desk time there could be much better opportunities having short periods of inflexibility is probably not as problematic as never being able to decide over breaks or never being able to leave work even for urgent matters the factors in the benefit dimension were generally not very strongly associated with the outcome variables however several benefit factors were associated with increased workrelated control the possibility to exercise during work hours was also associated with higher work engagement women who had the possibility to exercise during work hours also tended to experience less worktofamily spillover compared to women who did not have this opportunity however it is important to notice that the question was about whether they had the opportunity or not not whether they took advantage of it there may be stronger associations with wellbeing among those who actually exercise during work hours salary compensation during parental leave was associated with less worktofamily spillover as well as slightly lower levels of workrelated demands in this case it is evident that the salary compensation is a proxy for something else in the work environment because at the time of participating in the study none of the parents were on parental leave and could therefore no longer benefit directly from a salary compensation thus such compensation is possibly related to attitudes on the work place indicating a positive attitude to parental leave except in the attitude dimension there were not many interaction effects between work place factors and gender indicating that in most cases the association between work place factors and outcome measures were similar among men and women this is partly in contrast with previous studies which have indicated differing effects among men and women 11 12 13 in general work place factors related to flexibility and especially among women attitude to parenthood appear to have the strongest effect on working parents subjective stress and wellbeing while benefits appear to have less impact the flexibility factors may increase the parents general sense of control over the life situation which may lead to beneficial health effects the importance of attitude may both reflect a direct effect of the experience of a positive attitude but also be associated with a generally friendly atmosphere allowing for individual solutions and understanding of special needs and circumstances associated with the parenthood still the individual effect of different work place factors may vary much between individuals which may reduce the overall effect or association for each work place factor most likely different factors are better suited or more important for some individuals than others depending on their total work as well as family situation and also depending on individual factors such as personality priorities etc an example of this was seen in a previous report where while some factors were among some parents ranked high as stressreducing factors the same factors were also by some parents considered to potentially increase the stress 23 in order to find the optimal work environment for the employee the employer should perhaps discuss different options with the employer to find the optimal solution for each individual future longitudinal or intervention studies may further explore potential causal effects of work place factors or change in working conditions effects may also differ between different occupational groups position etc which may be explored through larger samples allowing for stratified analyses or selected samples knowing more about the impact and possibilities for work place factors to facilitate the combination of employment and parenting while maintaining work engagement as well as good health and minimising stress fatigue and physical symptoms could possibly be a link in the prevention of more severe stressrelated health problems and a perhaps reduce sick leave in this potentially strained population conclusion knowing more about the associations between work place factors and health could help employers to form a work environment that provides optimal conditions for health and work engagement among working parents since the need for a lasting and durable combination of parenting and employment is a reality for many parents today increased knowledge about these associations is of great public interest as well as occupational health interest most likely different factors are better suited or more important for some individuals than others depending on their total workas well as family situation and also depending on individual factors such as personality and priorities however the results from the present study indicate that a positive attitude towards parenthood and a flexible work situation seem beneficial for the general wellbeing and work engagement among working parents conflict of interest the authors declare that there is no conflict of interest

the need to combine active employment and parenthood is a reality for many parents today knowing more about which work place factors are associated with better or worse health could help employers to form a work environment that provides optimal conditions to maintain or increase health and work engagement in this group the aim of this study was to explore possible associations between different subjective and objective work factors and benefits and a range of outcome variables such as stress symptom report wellbeing workrelated fatigue work engagement and workfamily conflict among working mothers and fathers with small children methods crosssectional analyses of associations between work place factors categorised into three different dimensions flexibility benefits and attitude and the outcome measures were performed including questionnaire responses from 1562 working parents results the results showed that work place factors related to flexibility and especially among women attitude to parenthood appear to have the strongest effect on working parents subjective stress and wellbeing while benefits appear to have less impact except regarding factors related to attitudes at the work place most associations were similar among men and women conclusions most likely different factors are better suited or more important for some individuals than others depending on their total work as well as family situation and also depending on individual factors such as personality and priorities a positive attitude towards parenthood and a flexible work situation seem however beneficial for the general wellbeing and work engagement among working parents

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introduction recent years have seen an increasing amount of attention from the computational social science in the study of opinion formation and polarization over social networks with applications ranging from politics to brand perception 1 2 3 much of this research leverages preexisting opinion formation models that have been studied for decades 45 these models formalize the fact that people form their opinions through interactions with others one of the bestknown models is the degroot model 6 which considers an individuals opinion as dynamic and updates it iteratively as the weighted average of the individuals current opinion and those of her social neighbors the weights represent the strength of the social connections the degroot model is elegant and intuitive and it guarantees that the opinions converge towards a consensus 46 however opinions formed with it cannot polarize which contradicts empirical observations 78 variants of the degroot model have been proposed to incorporate biased assimilation 910 which is also known as confirmation bias or myside bias and refers to the phenomenon where information that corroborates someones beliefs affects those beliefs more strongly than information that contradicts them 11 incorporating biased assimilation has been shown to potentially lead to polarization 10 or opinion clustering 9 an extreme manifestation of confirmation bias is a behavior known in social psychology as the backfire effect 1213 it refers to the fact that when an individual is faced with information that contradicts her opinion she will not only tend to discredit it but will also become more entrenched and thus extreme in her own opinion the backfire effect may help explain the emergence of polarization yet it has so far been overlooked by existing opinion formation models motivated by these observations we propose a novel opinion formation model that simultaneously models the backfire effect and biased assimilationthe beba model beba depends on a singleintuitive nodedependentparameter β i which we call the entrenchment of node i the parameter captures both the tendency of node i to become more entrenched by opposing opinions and the bias towards assimilating opinions favorable to its own our main contributions are • we propose the beba model of opinion formation which accounts for both the backfire effect and biased assimilation to the best of our knowledge beba is the first degroottype opinion formation model that incorporates the backfire effect • we theoretically analyze the beba model studying conditions for reaching consensus or polarization • we empirically evaluate on real and synthetic data the influence of the entrenchment parameter the initial opinions and the network topology on the opinion dynamics of beba related work opinion formation has been studied in diverse research fields from psychology and social sciences to economics and physics 45 the former mostly use empirical methods to understand the factors that affect opinion formation while the latter mostly aim to understand emergent behavior implied by these theories two observations from psychology and social sciences relating to our work are the biased assimilation and backfire effect 1415 which state that individuals are more inclined to accept opinions closer to their own 11 and that when exposed to the opposite opinions individuals entrench themselves in their own opinions 121617 respectively the existence of the backfire effect is controversial it is observed in many studies but there are also failures to find the evidence of it 1819 for example it is reported negligible on reddit in a recent study 20 however the result may not be robust because the expressed opinions gathered on reddit are not necessarily consistent with peoples intrinsic opinions 21 the backfire effect remains to be further investigated on improved measures and experimental designs 19 and our modeling of it serves that purpose we study the common setting where opinions are formalized as real values formed through social interactions existing opinion formation models can be described as linear or nonlinear depending on how the opinions are represented 22 the most popular models include the voter model 2324 the degroot model 6 and the friedkinjohnsen model 21 yet none of these account for the biased assimilation or backfire effect there is work on modeling the fact that users are more influenced by opinions closer to their own the bounded confidence models 25 26 27 assume that a user is influenced only by one of the authors abir de at githubio when accessed on 21st january 2019 however we cannot publish their data because they were not collected by us and we do not have the right to share what we can do is to provide more information according to our experience the author abir de we contacted before was quite helpful and responsible thus we hope other researchers would be able to access the data by contacting the authors of the relevant papers the specific datasets we use are twclub barcelona getting the rst place in laliga from 8th to 16th may 2016 twsport champions league nal in 2015 between juventus and real madrid from 8th to 16th may 2015 twus presidential election in the unitedstates from 7th to 13th april 2016 tw uk british election from 7th to 15th may 2015 twdelhi delhi assembly election from 9th to 15th december 2013 twgot the promotion on the tv show games of thrones from 4th to 12th may 2015 more details of the twitter datasets can be found in appendix k of 1 and appendix g of 2 opinions that are within � of its own with rewiring and the relaxation of the bound the variations of the bounded confidence model are used to further model confirmation bias and polarization in the formation of public opinion 28 the work of kempe et al 29 assumes that there are different types of opinions and users are influenced by opinions of similar types das et al 30 consider a biased version of the voter model that biases individuals to adopt similar opinions the work most closely related to ours is that of dandekar et al 10 who propose a variant of the degroot model to capture the biased assimilation effect their model is called the biased opinion formation model and we treat it as our baseline because both ours and the bof model are degroottype in the bof model the importance that a node attaches to the opinion of a neighbor depends on their agreement however it cannot model the backfire effect and introduces cognitive irrationality we will contrast and highlight the differences between the two models with an illustrative example after formally introducing our model before that the detailed definition of the baseline bof model together with that of the vanilla degroot model will be introduced in the following section as background of our work model definition in this section we first describe the notations and two existing models that are most relevant to our work then we formally introduce our nonlinear opinion formation modelbeba which generalizes the degroot model and accounts for both backfire effect and biased assimilation finally we provide a comparison between beba and the bof model on an illustrative example to contrast and highlight their differences preliminaries and background notation let g denote a connected undirected network with v 1 n the set of nodes and e � v × v the set of m e edges where 2 e iff 2 e when the network is weighted w ij w ji represents the weight of edge we use n to denote the set of neighbors of node i n ≜ j 2 v 2 e all models we include in this work can be defined as dynamical systems where opinions are real numbers updated iteratively within a fixed interval of 0 1 or 1 1 to discriminate between the two intervals we use x for opinions in 0 1 and y for opinions in 1 1 we use x i to denote the opinion of node i at iterationtime t 012 x to denote the opinion vector of the network at time t x i to denote the opinion of node i after convergence for t 1 and x to denote the corresponding vector the degroot model this model 6 is an averaging opinion formation model where the individuals opinion is determined by the average of her own opinion and that of her neighbors more specifically the updating rule is x i ðt þ 1þ ¼ w ii x i ðtþ þ p j2nðiþ w ij x j ðtþ w ii þ p j2nðiþ w ijð1þ where w ii represents the extent to which the node values her own opinion and w ij is the strength of the connectionfriendship between node i and j iterative opinion updates will converge to a stationary state where every node has the same opinion x i x � 4 therefore the model always reaches consensus and never polarizes biased opinion formationbof the bof model 10 generalizes the degroot model to incorporate biased assimilation given a weighted undirected graph g every node i 2 v is assigned a bias parameter b i � 0 higher values of b i means that node i is more biased towards her own opinion the opinion value x i 2 0 1 is interpreted as the degree of support for opinion position 1 while 1 x i is the support for 0 bof is defined by x i ðt þ 1þ ¼ w ii x i ðtþ þ ðx i ðtþþ b i s i ðtþ w ii þ ðx i ðtþþ b i s i ðtþ þ ð1 à x i ðtþþ b i ðd i à s i ðtþþð2þ where s i ≜ ∑ j 2 n w ij x j is the weighted sum of is neighbouring opinions and d i ≜ ∑ j 2 n w ij is the weighted degree of node i during the updating process node i weighs confirming and disconfirming evidence in a biased way weighing the neighboring support for opinion 1 by ðx i ðtþþ b i and that for opinion 0 by ð1 à x i ðtþþ b i when b i 0 the bof model is identical to the degroot model however when b i 6 ¼ 0 this model introduces cognitive irrationality since an individuals opinion will change even when the neighboring opinion is the same to its own we will show that our model does not suffer from this problem the beba model we now define the beba model which also generalizes the degroot model to incorporate not only biased assimilation but also the backfire effect to capture both phenomena we adapt the degroot model by dynamically setting the edge weights for beba the opinion vector at time t is y with y i 2 1 1 rather than using fixed weights as in the degroot model we propose to let the weights be determined by the opinions specifically for an edge 2 e we define the edge weight w ij at time t as w ij ðtþ ¼ b i y i ðtþy j ðtþ þ 1ð3þ the product y i y j captures the degree of agreement between the opinions of node pair the parameter β i 0 which we call the entrenchment parameter of node i determines the level of the influence caused by that agreement with node j on is updating with w ij the larger the stronger the biased assimilation and backfire effect given the weights w ij the opinions in the beba model are updated similarly to the degroot model y i ðt þ 1þ ¼ w ii y i ðtþ þ p j2nðiþ w ij ðtþy j ðtþ w ii þ p j2nðiþ w ij ðtþð4þ note that when β i 0 the beba updating rule is identical to that of the degroot model for unweighted networks when β i 6 ¼ 0 we discriminate two cases depending on w ij 1 backfire effect is modeled when w ij 0 we consider two cases negative weight means β i y i y j 1 since β i 0 y i y j 0 that is nodes i and j hold opposing views multiplying y j with this negative weight w ij in the summation in the numerator leads to a contribution of the same sign as y i while adding the negative weight to the denominator reduces it inflating the resulting quotient the combination of these two effects models the backfire effect 2 biased assimilation is modeled when w ij 0 1 β i y i y j 0 here nodes i and j hold opposing but not too different opinions node i critically evaluates the conflicting opinion of node j but still assimilates it to a reduced extent 0 β i y i y j since β i 0 node i and j have both positive or negative opinions here resulting in an increased weight w ij in this case node i assimilates the opinion of neighbor j more strongly if the extent of their agreement is stronger note that the denominator in eq can become 0 resulting in a diverging opinion or negative causing an unnatural opinion reversal we consider this situation to be beyond the models validity region and thus we refine the beba updating rule as follows y i ðt þ 1þ ¼ sgnðy i ðtþþ if w ii þ 8 ð5þ moreover for a small denominator the resulting opinions may fall outside the range 1 1 to address this we additionally clip negative and positive values at 1 and 1 comparison between beba and bof there is a similarity between the bof and our beba model in that both alter the weights in the degroot model comparing to the linear degroot model both beba and bof are nonlinear now we study how the two nonlinear models differ with an illustrative example using a star graph consisting of five nodes we update the opinion of the center node with both models for one iteration and observe how the resulting opinions for the two models differ first we deal with the fact that bof assumes only positive opinion values while our model assumes opinions being both positive and negative note that the value range of opinions is important in both models since the bof model weights the opinion values while our model exploits the disagreement in the sign to compare the models we assume positive opinion x i 2 0 1 on all nodes for the update of bof and we transform them to 1 1 by setting y i 2x i 1 for beba after computing y 1 with beba we rescale the opinions back to 0 1 in this experiment we assume x i identical for nodes i 2 3 4 5 and x i 2 0 1 for all nodes we set w 11 1 for both models b 1 1 for bof and consider the values of 1 and 25 for β 1 in beba the opinion value x 1 updated with both models as a function of x 2345 and x 1 is shown in fig 1 the difference between the two models becomes clearer when x 1 takes extreme values and we study this below fig 2 shows the curves for the two models when x 1 0 in bof the opinion x 1 remains unchanged at value 0 this is true regardless of the value of b 1 thus extreme nodes never change their opinions even a little even when they are not biased at all however according to biased assimilation unbiased individuals are influenced by similar opinions and even extreme nodes assimilate opinions that are close to their own in contrast our model better captures the biased assimilation in this case in fig 2 for β 1 1 which corresponds to a mildly biased node the opinion of node 1 can be moderated by that of her neighbors to different extents while x 1 never exceeds 05 therefore extreme nodes are not stuck in the extremes to further highlight the difference between the two models and better understand the backfire effect we increase β 1 to 25 and set x 1 025 as shown in fig 2 in bof x 1 becomes smaller than x 1 025 even when all neighbors are holding the same opinion x 2345 025 which does not make sense according to 13 but in beba we make sure that node 1 does not react to persuasion that coincides with its own current opinion see point meanwhile we observe the backfire effect with beba that when the disagreement between node 1 and her neighbors becomes large 09 x 1 drops under 025 until it takes the extreme at opinion 0 from the plots in fig 2 we also observe that for the different combinations of β 1 and x 1 there exists a value of the neighboring opinions that causes the largest change in x 1 for example when β 1 1 and x 1 0 neighboring opinion of around 075 is the most influential as shown in fig 2 for β 1 25 and x 1 025 opinion around 07 is the most influential according to fig 2 this provides insight on influence maximization and misinformation correction that a moderate opinion could be more effective than an extreme one theoretical analysis this section contains theoretical analysis of the beba model for two settings first we investigate the dynamics of opinions for a single agent in a fixed environment and secondly we study the dynamics of polarization for all nodes in a connected social network a single agent in a fixed environment here we theoretically analyze the limit behavior of a single agents opinion in an environment with a fixed opinion an analysis of this type has been done for the bof model the setup is admittedly somewhat artificial but helps to gain a better understanding of beba it has been deemed realistic in cases where the fixed environment consists of the news media billboards etc 10 it also models the situation where the single agent is connected to a network that is large enough such that adding that agent will not meaningfully affect the network for the agent i we denote y 2 1 1 its opinion at time t β 0 its entrenchment parameter and y its converged opinionlim t 1 y we assume the agent weighs its own opinion with w ii w for simplicity we only consider the situation where the environment contains one node but it should be noted that the analysis below can be easily generalized to several nodes let p 2 1 1 be the fixed environmental opinion then according to beba the agent updates its opinion as yðt þ 1þ ¼ sgnðyðtþþ if w þ bpyðtþ þ 1 � 0 wyðtþþbp 2 yðtþþp wþbpyðtþþ1 otherwise 8 ð6þ before stating a theorem that quantitatively characterizes the limit y we consider the behavior in two cases the first case is for a sufficiently small β while the second is for a sufficiently large β in the first case the fixed environments opinion p will be sufficiently attracting such that y p regardless of y the same is true when p 0 the neutral opinion is never polarizing and thus always attracting the second case can further be divided into three subcases as the limit y will depend on the similarity between y and the environments opinion p if y is similar to p p should have an attracting effect on y such that y p if y is very different from p however the backfire effect will cause the agents opinion to diverge from p such that y sgn between the former two subcases there will be a sweet spot where y is neither sufficiently similar to p for y to converge to p nor sufficiently different for it to diverge to sgn this is an unstable equilibrium where y remains constant through time ie y y this intuition is formalized in the following theorem for conciseness and transparency we state it for the situation where p � 0 as it is trivial to adapt the theorem for p � 0 theorem 1 for a single agent with opinion y and entrenchment parameter β in a fixed environment represented by opinion p depending on the value of β relative to p case 1 when p 0 or β 1p the agents opinion always converges to p y p case 2 when p 0 and β � 1p there are three possibilities depending on how similar y is to p as illustrated in fig 3 a if yðtþ à 1 bp y will be sufficiently attracted to p such that y p b if yðtþ à 1 bp y will diverge away from p such that y sgn 1 c if yðtþ ¼ à 1 bp y will remain constant through time such that y ¼ à 1 bp theorem 1 already suggests that opinions under the beba model evolve to one of three possible states consensus as in case 1 and case 2 polarization as in case 2 and an unstable state of persistent disagreement as in case 2 polarization and consensus for all nodes in a network we now extend our analysis from the single agent to a group of individuals that can update their opinions at any time step t the dynamics of polarization are investigated theoretically with respect to different values of the entrenchment parameter β it was argued by the authors of the bof model that homophily alone without biased assimilation was not sufficient for polarization in the degroot model 10 as for beba the backfire effect and biased assimilation are sufficient to lead to polarization or consensus depending on the parameters and the initial opinions even when there is no homophily the theorem below makes this clear by providing easytorealize sufficient conditions for polarization or consensus to occur theorem 2 let g be a connected unweighted undirected network for all i 2 v let y i 2 1 0 0 1 be the opinion of node i at time t w ii 1 and β i β 0 for all i 2 v denote y the opinion vector of g at time t y the vector with the absolute values of all opinions then at convergence the beba model can lead to the following states 1 polarization when b 1 ½minjyð0þj� 2 8i 2 v y i 1 and there exist both opinion 1 and 1 consensus when b 1 ½maxjyð0þj� 2 there exists a unique y � 2 maxy maxy such that 8i 2 v y i y � a special case of particular theoretical interest is when miny maxy then there are only two different opinions in the network with the same absolute value but opposite signs in this case a borderline situation emerges to which we refer as persistent disagreement it can be proved concisely by relying on theorem 2 and thus we state it as a corollary corollary 1 let g be a connected unweighted undirected network where v v 1 v 2 v 1 v 2 for all i 2 v let w ii 1 and β i β 0 assume for all i 2 v 1 y i y 0 and for all i 2 v 2 y i y 0 for some 0 y 0 1 then the beba model can result in the following states 1 polarization when b 1 y 2 0 8i 2 v y i 1 and there exist both opinion 1 and 1 persistent disagreement when b ¼ 1 y 2 0 8i 2 v 1 y i y 0 and 8i 2 v 2 y i y 0 for all t 0 � 0 3 consensus when b 1 y 2 0 there exists a unique y � 2 such that 8i 2 v y i y � intriguingly these conditions in theorem 2 and corollary 1 are independent of the network structure and depend only on the entrenchment parameter β and the opinion vector at time 0 yet it should be noted that the value of the consensus and the eventual polarized state do depend on the network structure moreover the network structure and the distribution of the opinions over it do determine whether polarization or consensus will arise when neither of the sufficient conditions of theorem 2 are satisfied these claims are confirmed in experiments in the next section experimental analysis in the previous section we provided sufficient conditions for our model to reach consensus or polarization we now perform an experimental analysis of how these two phenomena manifest themselves on real and synthetic data our goal is to answer the following questions • in the case when consensus is reached what is the value of the consensus opinion and how does the entrenchment parameter β the initial opinions y and the network structure affect this value • in the case when the opinions polarize what is the state of the polarization and how is it affected by the entrenchment parameter β the initial opinions y and the network structure we use both realworld and synthetic data in our experiments the real datasets include zacharys karate club network 31 where we use synthetic opinion vectors and six twitter networks from 3233 that are gathered with real opinions for different events ranging from political elections to sports to fit our setting we process the twitter networks to make sure that their adjacency matrices are symmetric see s1 table for network statistics meanwhile following the way of processing the real opinions in 34 we normalize the first set of opinions for each event into range 0 1 after that we transform the opinions to 1 1 for beba the synthetic networks which are used with randomly generated opinions are • erdősre ´nyi networks g with binomial degree distributions where ρ is the edge probability 35 • wattsstrogatz networks g that have the small world property 36 with k being the average degree and σ the rewiring probability • baraba ´sialbert networks g that are scalefree where m 0 is the number of initial nodes and m the number of nodes a new node is connected to 37 the influence of the entrenchment parameter β from theorem 2 we know the stationary opinion vector y of our model polarizes when b 1 ½minjyð0þj� 2 and reaches consensus when b 1 ½maxjyð0þj� 2 these thresholds are far away apart in practice the transition between consensus and polarization occurs at a value much lower than 1 ½minjyð0þj� 2 and higher than 1 ½maxjyð0þj� 2 we now take the karate network as an example and examine the relation between β and polarization experimentally using random initial opinion vectors let β p denote the threshold between consensus and polarization for an opinion vectorthe smallest β that results in polarization more specifically what we observe is that consensus is reached when β β p and the stationary opinions polarize when β � β p since we do not restrict opinions to be only y 0 and y 0 as in corollary 1 there is no persistent disagreement observed in our experiments also note that even though we assume the identical entrenchment parameter for all nodes in a network both in the theoretical and experimental analysis the chances are people will have different levels of entrenchment in the real world fig 4 shows the distribution of the empirical β p values for 10000 different random opinion vectors where each opinion is uniformly sampled between 1 1 the value of β p for each random opinion vector is found by grid search from 0 to 10 at a step size of 01 we observe that the threshold for polarizationβ p is much smaller than the theoretical value which should be around 10 4 according to the sampled opinions however on the karate network the empirical value of β p is below 5 for most of the random y and never exceeds 7 we further study the opinion dynamics for one individual opinion vector from the 10000 samples fig 4 shows the variance of its stationary opinions as a function of β we observe that as β increases the opinion vector converges from consensus to polarized states the variance stays zero if there is consensus while when the variance is greater than zero polarization is obtained for this y the transition from consensus to polarization happens at β p 22 and no persistent disagreement was observed when consensus is reached the influence of the initial opinions y in this experiment we investigate the influence of y on the consensus opinion value and the mean polarized opinion we observed that the consensus value as well as the mean polarized opinion are strongly correlated with the mean of y as shown in we also investigate the influence of the initial opinions on realworld dataset twclub with real opinions on whether barcelona was getting the first place in laliga 2016 and tw sport with opinions on whether juventus or real madrid is winning the champions league final in 2015 have the same network but different opinion vectors 32 thus suitable for this evaluation we found that the β p is 117 for twclub and 33 for twsport the results indicate that the support behavior for different football clubs gets polarized more easily than a single yes no question with beba we are able to quantify how easily peoples opinions on an event may get polarized the influence of the network g in this experiment we study how the network topology affects the β p value and the stationary opinions of our model to this end we generate random networks of the three models with the same number of nodes and similars number of edges and intialize the same opinion vectors y for them we observe that different network properties result in different dynamics of polarization shown in fig 6 are the distributions of the β p values on the three models for the same set of y the ba model has a larger standard deviation of the β p values which appears to be due to hub nodes whose opinions strongly affect the value of β p the er model has similar mean of β p to the ba model which is larger than that of the ws model as the ws model with the rewiring probability 1 essentially approaches the er model our ws network with less randomness in fig 6 shows a tendency to get polarized more easily than the er model it indicates that for the same set of opinion vectors on different issues the more randomness the network has the more robust the network is against polarization to further verify this we do similar experiments with the same set of opinion vectors on the ws models with more rewiring probabilities of 01 03 and 08 see fig 7 it shows that as the rewiring probability of the ws model increases the mean of β p becomes larger which confirms our observation that the randomness in networks correlates with the networks resilience against polarization the consensus values reached by the same set of opinion vectors on the three types of networks are plotted in fig 6 the shapes of scatter plots become increasingly compact from the ba model to the er model and then to the ws model indicating the largest and the smallest variance on the consensus opinions for the ba and the ws network respectively the large variance for the ba mode is caused by the hub nodes comparing to the er mode the the placement of the edges and the parameters in each model also affect the opinion dynamics we take the er model as the example and investigate the influence of g with a fixed and a changing ρ for one random opinion vector on 1000 er networks with ρ 04 the β p as well as the consensus opinion for that opinion vector vary see s2 fig if we increase ρ from a small value which still guarantees a connected network to 1 we observe quite different β p for that opinion vector even with similar values of ρ while when ρ gets closer to 1 meaning that the network gets more connected that β p becomes more stable see s3 fig the results are similar for the consensus value and the polarized opinion realworld dataset analysis using the six realworld twitter datasets 3233 we investigate how easily each event gets polarized opinions namely the value of β p it is shown in table 1 that political events concerning elections in the first row are less likely to polarize since they require a relatively high β p however the 2016 us presidential election shows a tendency to get polarized more easily than the other two elections with a lower β p on the other hand the tv and sport events are more likely to get polarized except when people have to bet on a result instead of supporting opinion manipulation under beba we also investigate the following question as a potential application of our model on opinion manipulation how will the opinion dynamics be influenced by edge addition or deletion in networks we use the karate network to study this question experimentally we observe that in order to maximally decrease the consensus opinion by editing one edge adding the edge between the most opinionated disconnected negative nodes is the best choice if allowed a single edge addition while deleting the edge between the most opinionated connected positive nodes is the best choice if allowed a single edge deletion similarly the maximal decrease of the consensus value can be achieved by adding the edge between the most positively opinionated nodes or deleting the edge between the most negatively opinionated nodes see s4 and s5 figs another interesting finding is that the connections between nodes with opposing equivalent opinions have almost no influence on the consensus value see s6 fig in contrast when the network gets polarized the neighbors of the neutral nodes have more significant influence on the mean polarized opinions conclusion and future work modeling how opinions evolve when individuals interact in social networks is an important computational social science challenge that has received renewed attention recently the availability of realistic models of this type may have substantial reallife impact on a variety of applications from political campaign design to conflict prevention and mitigation a large number of models have been proposed in the literature towards this end to the best of our knowledge however none of them model the socalled backfire effect the fact that individuals when exposed to a strongly opposing view will not be moderated but rather become more entrenched in their opinion here we proposed the beba model which models both biased assimilation and backfire effect it is governed by one parameter called the entrenchment parameter determining the strength of both the beba model naturally generates different behaviors from convergence to a consensus to polarization theoretical and empirical analyses demonstrate that the resulting model is not only practical its behavior also provides an interesting view on the interplay between network structure the entrenchment parameter and the opinions these properties make beba a useful tool for simulating the effect of interventions such as editing the network altering the initial opinions or affecting the entrenchment of particular individuals it has the potential to help with correcting the misinformation in the real world however beba has its limitations for example it would be interesting to investigate a variant of the model where the updated opinions naturally fall into the range 1 1 without the clipping we applied in eq also it would be interesting to explore the different parameters for the backfire effect and biased assimilation we plan to explore these directions in the future part of the data cannot be shared publicly because it was form a third party the thirdparty data were available at when accessed on 21st january 2019 please contact the corresponding authors of 12 if you do not find it when the access is needed among the real datasets we use the karate network is publicly available on many websites eg networkrepositorycomsockaratephp and it even has its own wikipedia page however the six twitter networks with real opinions were from 12 which we consider as the thirdparty data they were publicly available on the personal website of

the democratization of ai tools for content generation combined with unrestricted access to mass media for all eg through microblogging and social media makes it increasingly hard for people to distinguish fact from fiction this raises the question of how individual opinions evolve in such a networked environment without grounding in a known reality the dominant approach to studying this problem uses simple models from the social sciences on how individuals change their opinions when exposed to their social neighborhood and applies them on large social networks we propose a novel model that incorporates two known social phenomena i biased assimilation the tendency of individuals to adopt other opinions if they are similar to their own ii backfire effect the fact that an opposite opinion may further entrench people in their stances making their opinions more extreme instead of moderating them to the best of our knowledge this is the first degroottype opinion formation model that captures the backfire effect a thorough theoretical and empirical analysis of the proposed model reveals intuitive conditions for polarization and consensus to exist as well as the properties of the resulting opinions

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introduction banking as an indispensable service of daily life is undergoing unprecedented changes under the trend of the digital economy with the increasing penetration of highspeed internet and electronic devices digital banking has become increasingly pervasive 321115126 in addition to banking websites and mobile banking apps electronic payment services and virtual banks eg netbank 84 webank 118 monzo 80 recently emerged as alternative digital banking platforms moreover this trend has been accelerated by the covid19 pandemic many banks have shut down their physical branches and replaced them with more digital banking platforms 1252100109 as facetoface interactions in physical banks have been gradually replaced by digital user interfaces on websites and mobile apps researchers have investigated peoples experiences and attitudes toward online and mobile banking 4657128 and digital payment 66135 however such studies primarily focused on young adults compared to young adults older adults tend to use technologies to a lesser extent and feel more reluctant to adopt new technologies 2588111 they also tend to encounter more difficulties when using new technologies in general due to factors such as agerelated declines 4478132 generationcohort effects 132 digital dividebarriers 2090 and fewer educational opportunities to keep up with the technology 98 consequently older adults might face more challenges when adopting digital banking on the other hand compared to young adults older adults have accumulated more experiences with a variety of technologies over decades and may have different criteria for good technology as a result understanding what older adults have to say about technology would be beneficial for designing more inclusive technology not just for themselves but also for everyone after all aging is a process that everyone is experiencing 53 thus it is critical to understand older adults banking experiences to improve the accessibility of emerging digital banking platforms researchers have already begun to explore older adults digital banking experiences recently 203881899599136 while informative these studies primarily focused on specific aspects of digital banking such as the user experience of bank websites on desktop computers 38 strategies to build trust in internet banking 99 and the effect of selfefficacy and anxiety on internet banking 95 a recent survey study took a step further to understand older adults overall banking practices in light of recent technological development and found that although the majority of older adults still used physical banks a small percentage of them started to adopt digital banking and digital payments 48 however this survey study mainly provided a quantitative overview of older adults banking practices and it remains largely unknown why and how older adults choose to use different baking platforms and the challenges they encounter inspired by this line of work we took a step further to explore the following research questions • rq1 how do older adults use physical and digital banking platforms what are the perceived pros and cons of these banking platforms • rq2 what are older adults motivations for learning digital banking • rq3 what are the challenges that older adults encounter when using digital banking platforms to answer rqs we conducted indepth semistructured interviews with 16 older adults living in five cities in china china has the largest older adult population 8291 and has been undergoing a fast growth in digital banking for example china is a world leader in the adoption of contactless mobile payments with 811 usage penetration 3046 and has the highest growth rate of electronicpayment transactions among all countries 21 under this rapid transition to digital banking older adults in china have opportunities to experience both physical and digital banking platforms and may encounter challenges associated with various digital banking platforms furthermore we also conducted semistructured interviews with bank employees to gain an understanding of older adults banking experiences from their complimentary perspectives as helpgivers these bank employees had direct interactions with older adults and accumulated experiences when assisting older adults with their banking needs our findings show that older adults used both physical and digital banking platforms they performed different types of transactions on different platforms based on their perceived pros and cons moreover our study uncovered three motivations for learning digital banking which were perceived usefulness selfconfidence and social influence furthermore our study found that older adults encountered apprelated challenges and userrelated challenges when using digital banking platforms we found that although older adults encountered challenges they showed a strong willingness to learn and apply their accumulated experiences and knowledge to tackle the problems first before seeking help from ones whom they trust taken all together we further discuss the implications of our key findings and propose design considerations and future work for assisting older adults with overcoming challenges in using digital banking and for supporting helpgivers to better assist older adults in sum we make the following contributions based on both older adults and bank employees perspectives • an understanding of how older adults use physical and digital banking platforms and their perceived pros and cons of these platforms • an understanding of the motivations to learn digital banking • an understanding of banking challenges and design considerations to improve older adults banking experiences background and related work banking trend and technology adoption for older adults banking services are increasingly digitized with the development of information and communication technology 5 at the same time physical banks also constantly reduce the number of branches and staff to save money 74 while digital banking could bring convenience to people who are adept at digital technology such a rapid technological shift may pose challenges to people who are accustomed to traditional physical banking such as older adults prior research suggested that older adults tend to adopt new technologies slower and may be less likely to use technologies in general than young adults 2588111 olson et al conducted a survey study with 430 younger adults and 251 older adultsand found that older adults tend to be frequent users of longstanding technologies and less frequent users of more recent technologies 88 digital banking was also found to be not as popular among older adults as it was among the young in asia 73 possible reasons for this age difference could be the agerelated health declines and the digital divide among older adults agerelated perception declines like vision impairments may make it more difficult for older adults to perceive small icons when using technology devices 2679 and agerelated physical declines like reduction in fine motor skills can cause older adults to encounter more motor issues such as tapping and scrolling when using mobile apps 129 and agerelated cognitive issues such as the reduced speed of learning and memory difficulties may also slow down their learning of digital technologies 28 moreover older adults were exposed to a different set of technological products when they were in the workforce compared to younger generations 2090 which could potentially contribute to the digital divide between older and young adults as a result as an emerging new technology digital banking might impose new challenges for older adults especially under the current covid19 pandemic people in many countries are advised to avoid using inperson banking to ensure the inclusiveness of digital banking for older adults it is critical to understand how older adults perform banking activities on digital banking platforms and the associated challenges in this work we seek to explore this question with older adults in the context of china china has the worlds largest and fastestgrowing aging population 8291 it is estimated to have 280 million older adults by 2025 which will represent about onefifth of its total population 7091 at the same time the development of the digital banking and ecommerce market in china is among the fastestgrowing in the world with a volume of 194 trillion usd in 2019 2946 and has almost become a cashless economy with the fastest growing electronic payment 215468 as a result older adults in china have been experiencing the fastest shift from traditional physical banking to digital banking and may experience more challenges when learning and using new banking platforms by studying the banking practices and challenges that older adults in china experience we hope to reveal design opportunities to better improve the banking experience for the aging population older adults banking practices physical banks are commonly used by older adults 124489 and older adults were found to prefer to visit bank branches over conducting banking transactions online 147289 inperson customer service offered in physical banks was rated as one of the top desired services from financial institutions among older adults 1 despite the familiarity with physical banks older adults complained about the inconvenience associated with visiting bank branches such as the long wait time 4889 the automated teller machine was a technological innovation to traditional banking products 2085 and the adoption rate of atms among older adults has been slowly increasing over the past decades 274192102133 nonetheless many older adults still do not use atms 48 one critical reason was that older adults felt uncomfortable and less in control of their finances when using an atm 27 obrien et al further identified more factors influencing atm adoption among older adults which include usefulness compatibility complexity technology generation and relative advantage of a technology 92 compared to traditional atms newer versions of selfservice banking machines such as cash recycling system machines could handle more banking transactions these crs machines typically have a big touchable screen and can handle many banking transactions in this paper we treat all of them as atms digital banking platforms such as bank websites and mobile banking apps have recently emerged as alternatives to physical banks and atms 5 researchers investigated whether and to what extent older adults adopted digital banking platforms compared to young adults older adults tend to use digital banking to a lesser extent and preferred to use the traditional banking platforms 738889 furthermore researchers investigated the factors to affect older adults adoption of digital banking platforms including the user experience of banking websites 38 trust 99 fear 136 and selfefficacy and anxiety 95 in sum prior research primarily focused on the adoption of a particular type of banking platforms among older adults however it remains unknown the practices and challenges of banking on both physical and digital platforms among older adults and how they make tradeoffs between these platforms furthermore electronic payment services and virtual banks are the latest technological development in banking although a few studies began to explore the use of electronic payment services and virtual banks among young adults 66135 few focused on older adults recently a survey study showed that electronic payment had a higher adoption rate than mobile banking and even atms among older adults in china 48 this has motivated us to understand the practices and challenges of using electronic payment and virtual banks among older adults as well as other banking methods such an understanding may potentially explain why electronic payment despite coming around the same time as mobile banking and virtual banks 124125127 and about 30 years later than atms 85 has gained popularity in such a short time in this work we seek to understand how older adults use physical and digital banking platforms how they learn to use digital banking platforms and the challenges encountered under current hybrid digital and physical banking services method to answer rqs we conducted irbapproved semistructured interviews with older adults to better understand their banking experiences moreover we also conducted semistructured interviews with bank employees who had experience helping older adults to gain a complementary understanding of the difficulties older adults encountered procedure we obtained approval to conduct this research from the institutional review board of our university interviews were held through phone calls video calls or inperson at participants places of choice by one researcher all local covid prevention protocols were strictly followed all participants spoke mandarin and we also conducted the interviews in mandarin while some participants voluntarily showed us their apps to explain their points our studies did not ask for or record any personally identifiable information the interviews lasted about an hour ranging from 47 minutes to 76 minutes and were audiorecorded each participant was compensated with 70 cny for older adult participants they were first asked to share their banking practices including the activities they performed on various banking platforms and the reasons for their choices following a semistructured format we asked them to freely talk about their usage patterns among these platforms and the challenges they encountered as well as the strategies they used to overcome the challenges specifically we asked participants to explain their problems by showing the issues with their apps for both inperson and videocall interviews for phonecallonly interviews we installed the same app as the participants to follow their descriptions of the problems lastly we asked about their expectations of banking platforms for banking employee participants they were first asked to estimate the proportion of older adult customers and their queuing status and to share their observations and experiences regarding older adults practices and challenges of using physical counters and digital banking methods they were also asked to talk about the types of transactions that they often help older adult customers with after that they were asked to share the difficulties they encountered when helping older adult customers and their banks policies for older adults finally they were asked to share how they felt banking systems could be improved to better help older adults data analysis the interview recordings were auto transcribed and one native mandarinspeaking author reviewed and corrected the transcripts two mandarinspeaking authors first familiarized themselves with the transcripts and then coded them independently using an open coding method 22 they met to discuss their codes and rationals revise their codes and resolve disagreements to gain consensus on the codes after that all the codes were translated into english and all the researchers performed affinity diagramming 13 to cluster the codes and categorize emerging themes related to our research questions with an inductive approach we followed an iterative process to constantly challenge the groupings until we reached a consensus on the final groupings and their themes findings our analysis revealed three main themes about practices and challenges of banking among older adults 1 activities and practices on different banking platforms 2 motivations to learning digital banking platforms and 3 challenges in using digital banking platforms we refer to older adult participants as participants and bank employee participants as bank employees in the rest of the section activities and practices on different banking platforms fig 1 participants banking platforms and transactions an arrow from traditional bank accoun points to both physical banking platforms and digital banking platforms which indicates that these platforms could be bound with traditional bank accounts another arrow from virtual bank accoun points to virtual banks and electronic payments which indicates that these services could also be bounded with a virtual bank account different colors and types of the lines indicate the connections between the banking platforms and the corresponding transactions that older adult participants performed physical platforms participants primarily conducted the following transactions in physical bank counters deposit money withdraw money manage wealth and transfer money likewise participants also conducted a similar set of transactions on atms though they tended to use atms more often to check balances and details of their bank accounts banking transactions on physical and digital platforms bank employees estimated that older adult customers took up 30 to 90 of all the customers visiting physical banks depending on the bank branchs location the date and the time of day our analysis found that the wide range was mainly related to banks locations and types banks on the higher end of the range tended to be stateowned big banks with a long trustworthy history and locate in residential areas the ones on the lower end tended to be relatively small banks or locate in business districts moreover bank employees reported that older adult customers tended to flood to the banks around the time when pension payments are released which crowded the banks and overburdened the bank employees furthermore bank employees reported that older adults who did not use smartphones faced extra challenges during the covid19 pandemic because banks required their customers to scan the qr code to reveal their health code on their phones to prove they are healthy before being allowed to enter the banks which were complained a lot by them digital platforms participants used three main forms of digital banking platforms mobile banking apps virtual banks and electronic payment participants used two types of mobile banking apps to conduct financial transactions remotely one type was provided by traditional banks and they used this type of mobile app to transfer money manage wealth and conduct transactions related to a credit card bank employees confirmed that mobile banking apps provided by traditional banks provided the majority of the noncash banking transactions the other type was provided by or in collaboration with stock exchange such as eastmoney and dazhihui 103105 and participants used such apps mostly to perform wealth management such as buying stocks or funds virtual banks are the ones that do not have physical branches but offer banking services remotely 123 participants used virtual banks apps to deposit money to their electronic payment account pay bills and manage wealth furthermore participants also used the virtual bank as a bridge to transfer money between accounts in different physical banks they would first transfer money from one bank account into the virtual bank and then transfer the money again out to another bank account in such a way they could avoid a transaction fee associated with transferring money directly between two bank accounts because virtual banks have the benefit of waiving online transferring transaction fees electronic payment options include digital wallets contactless payment methods etc to use electronic payment participants needed to create a virtual account and bind one bank account with the virtual account so that they could transfer money from their bank account into the virtual account the two most commonly used electronic payment services among participants were wechat pay 119 and alipay 4 and participants used them regularly for daily activities such as buying groceries shopping online paying for meals taking bus or taxi and transferring money on the other hand the long wait time was a frequently mentioned disadvantage of physical bank counters bank employees reported that wait time was influenced by the banks location date and the time of a day for example wait time would be longer if a bank branch was the only one in the local area or if it was the pension release day especially on the day of pension release sometimes even before the bank branch is open people have already filed a long line at the bank gate moreover they mentioned that to comply with improving regulatory requirements the transaction processes became longer than before which further increased wait time atms atms were perceived to be convenient and timesaving for certain banking transactions such as withdrawing money however participants complained that they were unable to find out whether atms had enough cash until they inserted their cards and were several steps into the process whats more participants were concerned about the legibility of the atms screen and often had to deliberately bring reading glasses to overcome this problem who would always remember to bring the reading glass when going outp1 indeed bank employees also shared similar feedback from older adult customers and pointed out some bank branches started to provide reading glasses to customers moreover participants were also concerned about the fact that others could spot their passwords over their shoulders when they used atms furthermore bank employees mentioned that the latest versions of atms allowed customers to sign on the screen using a digital pen however many older adults had hand tremors which made it difficult for them to sign on the screen digital platforms one common advantage of all digital banking platforms was convenience first with digital platforms participants could save physical efforts while still satisfying their banking needs at home i could pay utility bills using alipay with a few clicks and dont have to go outp2 those unnecessary human labors or human errors are saved by the information technologyp5 second participants did not need to carry and deal with banknotes which were susceptible to both hygiene and counterfeit issues in particular participants appreciated that they did not have to carry their purses or wallet to store cash but just needed to carry their smartphones which almost all of them would carry anyway when going out i used to carry a wallet and need another bigger bag to store it along with my phone now i only need to carry a small bag to store my phone p6 it helps to avoid touching paper bills and is more hygienic this is especially important during the pandemicp5 third participants could transfer the money instantaneously on digital platforms p5 preferred to use pocket money to transfer money to his daughter who studied far away over traditional money transfers in banks because the money would arrive at his daughter instantaneously to ensure her financial needs without delay on the other hand participants expressed privacy and security concerns about digital banking platforms because of the security concern about the electronic payment p7 did not directly bind her bank account with wechat pay instead she usually withdrew more cash from physical banks than she needed and exchanged the extra cash with her trusted relatives so that they could transfer money to her wechat pay moreover participants also had security concerns about offline transactions when paying a person offline using an electronic payment app the app typically generates a barcode and displays it on their phones screen for the person to scan however participants worried that passersby might be able to scan the barcode easily from a distance and steal their money a passerby could easily use their phone to scan the barcode on my phone from several meters away without my awareness so i never use it offline p7 motivations to learning digital banking platforms we identified three primary motivations for learning digital banking platforms perceived usefulness selfconfidence and social influence perceived usefulness participants felt that it was convenient to complete transactions for daily activities such as paying groceries and transportation fees on their smartphones especially for daily activities bank employees also reported that many older adults were willing to try digital banking platforms even if they had to wait in lines for a long time moreover they were also motivated by economic benefits such as discount activity on online shopping platforms after hearing from others that fruits on pinduoduo were cheap i started to learn to use wechat pay p16 similarly they were also motivated by the fact that many offline shops offered discounts when customers pay with electronic payment yunshanfu collaborates with local shops to offer discounts on their groceries such as tofu so i was motivated to learn to use itp8 additionally one participant was motivated by higher interest rates of wealth management products offered through mobile banking apps some wealth management products have higher interests but they are only available in mobile banking apps so it is worth learning p14 another perceived usefulness of learning digital banking platforms was to keep their brains sharp im getting old and if i dont use it ill lose it p14 selfconfidence overall participants expressed confidence in their ability to learn digital banking i might be slower than others but just because im slow doesnt mean i cant learn it p6 although i am slower than young people i could still manage to learn it p14 moreover their prior experiences with technology seemed to help them gain confidence in learning digital banking platforms p12 was used to learning things by himself because he did not live with his children for a long time many years ago i bought a computer and started to learn to type and i got used to this learning process over time so its not too hard for me to learn these operations on my phonep12 similarly p15 learned how to do wealth management on the website using a computer and felt it was relatively easy to transit conducting on mobile banking apps besides they tended to describe learning digital banking as troublesome instead of difficult it was troublesome to use mobile banking for wealth management because i only did it once per year but still had to remember the steps p4 last but not least they were able to afford the learning efforts in particular if they could receive some help along the way someone taught me how to use it and i felt it was not that hard to learn p1 social influence all participants mentioned that they were motivated by people in their social circles such as their children grandchildren and friends who almost all used digital banking platforms p15 mentioned that he decided to learn to use digital banking because he envied his colleagues for being able to use digital banking apps to buy breakfast much faster i was reluctant and resistant to learn it but later i noticed that my younger colleagues used their phones to pay for breakfast by simply scanning a code in contrast i had to carry change to pay for my breakfast which was much slower i really envied them and wanted to learn later they taught me how to use it p15 bank employees also reported that there are few older adults who would like to proactively propose to use digital banking methods to replace manual counters although most of the banking transactions could be conducted via digital banking platforms therefore bank employees provide active guidance and advertisement to encourage and lead older adults to use digital banking tools like mobile banking apps while there were still a large proportion of older adults who would rather wait a long time for the manual counters which consist with the findings of the study 48 some older adults were indeed motivated by their words and tried these new methods with their guidance moreover participants were motivated to learn because they were involuntarily connected with digital banking platforms through their social connections p16 started to learn digital banking because her friend transferred digital cash to her when paying her back she thought that she had to find a way to spend the money in the digital bank so she gradually learned to use electronic payment and now she could use it for online shopping furthermore participants felt that digital banking represented a societal trend and they needed to keep up with the fastchanging world and not become obsolete society is moving forward and new technology is beneficial for societal development p5 now everything is online so if you dont know how to do it online you will be outdated p6 lastly participants also felt proud of being able to use digital banking among their peers p8 and p14 regarded being able to use digital banking as a fashion i think learning digital banking is a kind of pride and fashionable p8 challenges in using digital banking platforms when using digital banking platforms participants encountered apprelated challenges and userrelated challenges apprelated challenges as for apprelated challenges p6s complaint may shout out many older adults thoughts it is not designed for our older adults it is designed for the youngp6 besides participants bank employees confirmed that many older adult customers complained about the poor design and defective accessibility of the banking app there were four types of apprelated challenges ambiguous affordance low information scent insufficient error recovery support and lack of feedback or confirmation ambiguous affordance participants did not realize certain functions existed due to the ambiguous affordance of ui elements for example fig 2 a shows a list of all types of transactions in march 2021 there was a gray triangle icon on the right side of the title when clicked the interface pops up a window which includes an all option for users to check their spending on all types of transactions and other options such as red packet transfer pay credit card for them to check the spending of a specific type however the triangle icon was not perceived as clickable as a result p1 believed that there was no way to check her total spending webank shows all transactions together when i had too many transactions i needed to check my spending on a specific category but i could not do it low information scent one symptom of low information scent was that participants had no idea certain functions existed in the app p5 was frustrated with not receiving realtime notifications about his spending when using the credit function of a virtual bank when the credit bill was due after a month he often found he spent more money than he realized it wasnt transparent and didnt send any notification in time i only realized the bill was higher than i expected after a month this confusion was caused because p5 did not realize that the realtime notification needed to be enabled in the settings moreover participants were also frustrated about being redirected from page to page atm has clear steps but the app does not you have to click here to enter a page then click there to go to another page and so on and so forth p1 bank employees reflected that it did happen commonly during the use of banking apps and it was a kind of burden for them to lead older adults to the exact page as well insufficient error recovery support the digital banking apps did not provide sufficient guidance for participants to recover from a mistaken operation i once clicked on a wrong thing and was taken to a completely different place i had no idea how to return to the previous step and became panicked in other situations i would have restarted my phone but this was related to money and i was afraid of losing money if i restarted my phone p6 thus p6 went to the bank to ask for help instead but she felt this approach was too costly to be a regular solution moreover insufficient error recovery support could also happen at the operating system level p8 reported that he once could not find the electronic payment app after he accidentally switched to other apps with an unintended touch gesture i didnt know how i switched to a different app from the wechat pay app i tried to swipe in different directions to get it back but i couldnt p8 actually participants expressed that they would like to do trial and error by themselves because they could learn without troubling others moreover they felt that learning independently would help them gain a deeper understanding and remember it longer if i learn and do it myself i would remember the process much better my wife always asked our kid to teach her and she still couldnt remember the steps thus getting help from others is no better than learning it by mep2 after receiving a text message with a link from his bank p2 clicked the link on his phone downloaded the banking app and tried to bind his bank card to it however without sufficient error recovery support he felt reluctant to try those unfamiliar functions in the app lack of feedback or confirmation participants also mentioned that their apps did not provide confirmation or feedback when they finished typing their bank account number and submitting it consequently they were unsure if they were successful or not and therefore were hesitant to continue the following steps the app has no confirmation after i enter the amount to be transferred as a result i have to check many times to make sure i have entered the correct information because of this i am afraid of transferring any large amount p9 432 userrelated challenges participants encountered the following userrelated challenges digital bankings intangibility trustworthiness security and privacy overspending concerns low perceived selfefficacy and memory concerns intangibility unlike physical banks that had a physical location and could provide printed receipts for transactions digital banks were perceived to be intangible i could not see what i buy in virtual banks p6 however the worry about abstraction seemed to go away as they gained more experience with digital banking over time i was hesitant to use digital banks in the beginning but i gradually accepted it after using it for a whilep3 trustworthiness the trustworthiness of digital banking platforms also made participants worry unlike physical banks in particular national banks that had been there in their entire lives digital banks were new they tended to think of digital banks the same as small local banks and worried about their trustworthiness they mentioned stories about the bankruptcy of small banks small local banks may run into cash flow issues and could even bankrupt like haifa bank so although i use digital banks i still worry about not being able to get my money out p5 participants doubts in small banks were reasonable none of the nationwise banks have bankrupted in china although rare one local bank did bankrupt in 1998 60 whats more digital platforms tend to be riskier than physical ones for example hundreds of digital peertopeer lending platforms were found to be fraudulent in 2018 122 the rampant fraud targeting older adults also made older adults more cautious and anxious about digital banking security and privacy the security and privacy of digital banking also caused anxiety participants mentioned that they heard about online hackers and data breaches in the news moreover they also worried about losing money due to mistakes in electronic payment what if there was a mistake in electronic payment and others swiped my cardp3 lastly unlike physical banks that offer printed receipts they felt virtual banks did not provide receipts that they could use to go and get the money back if unexpected things happened i dont have any physical receipts what if the digital bank disappears all of a sudden like the app is gone what do i do with my moneyp6 bank employees echoed that some older adults even did not trust the receipts printed by atms and only trusted the ones from a bank counter participants also mentioned privacy breach though they were unsure whether it was due to physical or digital banks i received a lot of spam calls from all over the country i didnt know who leaked my phone number but i suspected it was the banks since many calls are for loaning stuff p2 overspending concerns participants felt that it was harder to keep track of their spending when using digital banking and consequently they tended to overspend they sometimes i was surprised how much i had spent when i was reviewing my monthly billp6 it was indeed convenient but i ran out of budget much more easily using it than using cash with cash bills i was prompted to think again about how much i would spend p8 low perceived selfefficacy another userrelated issue was caused by low perceived selfefficacy one recurring symptom was being afraid of making mistakes this was because making mistakes would likely cause them to lose money when buying stocks in mobile apps i am extremely worried about making mistakes for example it is very easy to type an additional zero by accident p1 the concern about making mistakes was even severer when the mistakes were perceived as nonrecoverable reasons for low perceived selfefficacy included the lack of confidence in their literacy level and their declining physical conditions such as poor eyesight i dont have much education and it is common for me to press the wrong button p3 i recommended wechat pay to my sister however she resisted it because she was worried about making mistakes and losing money due to her poor eyesight p2 in this case they preferred to learn to use digital banking with assistance from their close peers their family members banking employees and classes offered by local communities and volunteers that made they felt reassurance about learning when deciding from whom to seek help participants reported considering both the trustworthiness and expertise of the help givers regarding trustworthiness participants preferred to be assisted by people who knew them well my children know my personality and knowledge level thus they would teach me at my level but others might start from a higher level they may be kind and helpful but i wont be able to understand it p8 moreover participants also worried that help givers might lose patience and assist them less carefully especially when there were other people waiting to get help from the same help giver indeed bank employee participants also reported that in peak hours they could only tell customers where to click with little time for an explanation so as not to keep other customers waiting for too long in some cases they would even operate directly on older adults phones instead of guiding them even though this was discouraged by bank regulations for privacy concerns the pressure of serving all customers in line is high so it is challenging to be always patient and meticulously in fact more often than not the regulation of never operating directly on customers devices was not well followed s6 from older adults point of view many were willing to let bank employees operate on their phones except for inputting the password to save time and effort many older adults mentioned that they had a bad memory and might forget it easily after being taught so it was better to operate it for them directly s1 furthermore some participants preferred help givers to monitor their operation process and only give feedback when they ran into trouble id like the bank employee to stand nearby to monitor my progress while im trying to do it on my phone i hope that he would help me only when i run into trouble otherwise i wont be able to do it next time p6 bank employee participants confirmed that many older adult customers wished to have them oversee their operations to spot mistakes and provide answers such as i am going to tap on this button are you sure i tap on the right button s2 moreover bank employees reported that many older adults had the ability to conduct transactions in banking apps by themselves the majority of them did the right operations all the time but they just wanted me there to confirm each operations2 eventually they still hoped to become as independent as possible to avoid troubling others young people are busy with their jobs i try to avoid bothering them and learn by myselfp6 to help themselves become independent participants felt it helpful to have a voice assistant whom they could ask for help it would be very helpful to have a voice assistant whenever i didnt understand it i could just ask for help i dont need to go to banks to ask their employees i dont want to bother others p7 meanwhile bank employees expressed their concerns that they might get impatient during busy hours with older adults asking repetitive questions as s6 reflected if some older adult customers keep asking me the same question while there are so many people waiting in lines my voice may sound impatient this might also explain why older adults feel bad about troubling others and want to be as independent as possible besides learning with others assistance during the usage of digital banking platforms participants developed four strategies to manage the risk of losing money first they set an upper limit for the amount of money that they would feel comfortable with even if they would lose it i only put in 1000 cny even if i became a victim of a fraud i would only have that much to lose which is manageable for me p3 second they would not directly bind their regular bank accounts with the digital platforms instead they bind a dedicated nonprimary bank account with digital banking platforms in this way they could avoid the risk of losing money in their primary bank accounts the third strategy was to practice and get familiar with digital banking platforms with a small amount of money first after several successful trials they would gradually increase the amount for example when p6 started to use her virtual bank she was concerned about whether it was easy to withdraw money from it after successfully withdrawing money several times she became more confident about it and started to put more money into it i just wanted to withdraw money from alipay to test if it worked after realizing it worked well i would deposit the money backp6 nonetheless participants still tended to set a maximum amount for digital platforms lastly they believed that avoiding petty discounts could also help them avoid falling for online frauds memory concerns another category of the userrelated issue was about forgetting various types of information related to digital banking first they were concerned about forgetting the steps of completing a bank transaction i followed the bank employees instructions to walk through the process step by step however if i didnt write it in my notebook i would forget about the steps p11 in addition they also worried about not being able to remember how to use many functions at the same time two of them mentioned that after mastering basic functions such as how to use electronic payment to pay bills they worried that they might forget how to use basic functions if they continued to learn more advanced functions i cant put too much information in my head otherwise i would mess it up and forget about it altogether p13 second they were also concerned about forgetting passwords p11 reported that she forgot the password and did not know how to find it back the mobile banking app asked her to set the password to be a combination of numbers and alphabets to ensure its security however such requirements increased the burden of memorization for older adults for example after many failed attempts p11 finally had to work with a bank employee to get her money back and never used the mobile banking app afterward discussion prior research investigated how older adults use physical banks 1 atms 83 and online banks 89 although some researchers studied how older adults use different banking platforms they primarily offered a quantitative overview of their usage via surveys 487288 moreover electronic payment services have been increasingly integrated into our societies in recent years in particular china has the highest growth rate of electronic transactions 21 and becomes the current world leader in the usage of proximity mobile payments among which 811 of smartphone users adopt proximity mobile payments 31 although a few recent studies explored how electronic payment services were used they mainly focused on young adults 6667135 while a recent study provided a quantitative understanding of how older adults use electronic payment through a survey study 48 it did not explain why older adults chose to use it over other banking methods building on top of prior work our work presents an indepth qualitative understanding of why and how older adults use both physical and digital banking platforms in todays technology landscape how they learned to use digital banking platforms and the challenges that they encounter in a country that has been experiencing one of the fastest growth of electronic transactions furthermore our work also provides complementary perspectives from bank employees to better understand older adults banking practices and challenges we discuss our key findings the design implications and potential future work in this section banking activities and practices frontline bank employees reported that almost all older adults came to the banks by themselves showing their intention to be independent older adults also had their own usage patterns with considerations of different platforms pros and cons although their understandings of different platforms varied in some aspects they generally agreed that security and timely inperson assistance are two advantages of physical banks with a series of visible secure checks and professional staff one the other hand the complexity of the secure process combined with other factors like the bank branchs location and the date also caused inconvenience such as the long wait time in physical banks in contrast using digital banking platforms could mitigate this issue and bring convenience for either conducting banking transactions online or paying offline without cash however it remains an open question of how to design a hybrid online and offline ecosystem to integrate the advantages of the two bank employees mentioned that almost all the banking transactions can be conducted through digital banking platforms except the cashrelated ones prior studies pointed out the two most common transactions conducted by older adults were money transfers and accounttransaction inquiries 154889 this is consistent with what we observed in our study participants frequently mentioned their experiences of transferring money and checking balances or details they also reflected challenges related to these two types of transactions which suggests that even the most common transactions still need to be improved future work could investigate ways to improve the accessibility of older adults commonly used transactions as a stepstone to increase their adoption of digital banking platforms furthermore both older adults and banking employees summarized the characteristics of banking transactions that older adults conducted as being relatively simple and having a relatively low risk reasons for not conducting more complex and risky transactions among our participants include the concerns of losing money and the lack of financial knowledge thus future work should investigate ways to help older adults confidently learn to perform more complex transactions potential cultural effects our study conducted with older adults living in china and their banking practices may have been influenced by the chinese culture that differs from those of western countries our participants reported some practices that were not found in western countries for example older adults in china widely use digital payment functions in wechat a social media app to pay for daily expenses in contrast we have not found a study reporting a similar trend in western contexts during chinese traditional festivals older generations often gift younger generations a physical red packet which is a red envelope with cash in it interestingly wechat allows them to continue practicing this tradition by sending a digital red packet with a similar visual effect to each other conveniently on the other hand there are common practices among older adults in western countries which are uncommon in china for example older adults in western countries regularly use personal cheques 158114 however people in china in general rarely use them moreover while it is common for older adults in western countries to use credit cards many major banks in china impose age restrictions on credit card applications and exclude older adults 117 this restriction might explain why older adults in china have less experience with credit cards 48 one reason for rejecting older adult applicants is that banks lack confidence in their ability to pay credit bills 117 however such a concern was not reported for western contexts in prior studies furthermore older adults in canada were reported to be comfortable with sharing online banking credentials with their close ties 58 in contrast our participants tended not to want to reveal their credentials to their close ties who would then know their financial status instead they were comfortable sharing their credentials with bank employees when seeking help because they felt that bank employees work ethics would not allow them to abuse their credentials in sum although our research scratched the surface of the potential effects of culture on older adults banking practices and challenges more systematic and substantial followup research is needed to further investigate the cultural effects motivations to learn digital banking we found that older adults learned digital banking with three primary motivations perceived usefulness social influence and selfconfidence these three motivations relate to several dimensions in the utaut2 model 112 specifically the perceived usefulnes relates to both expectation of performance and price value in utaut2 the social influence relates to social influence and the selfconfidence relates toexpectation of effort unlike the motivation of learning social technologies for communication such as reducing the loneliness which happens more prevalent in older adults 87106 participants learned digital banking because they felt that digital banking was convenient and offered economic benefits these motivations aligned with younger adults acceptance of online banking and electronic payments which included perceived ease of use perceived values and perception of utility 4666 in addition older adults felt learning digital banking could keep their brains sharp this echoes the finding of the previous study that older adults play digital games to help treat agerelated cognitive disorders 23 and learn computer programming to keep their brains challenged 43 compared to the literature the motivation to learn new technologies such as digital banking platforms for keeping brains sharp is perhaps a unique motivation among older adults while young adults rarely mention it as a motivation social influence was found to affect younger adults adoption and continued use of mobile payment services recently 67 our work extends this finding and confirms that it also affects older adults adoption of digital banking platforms participants were motivated by the adoption of digital banking among people in their close social circles and felt they should learn it to keep up with the social norms this motivation echos the previous research that older adults are motivated and encouraged by people around them such as their children and grandchildren to learn to use mobile phones and computer devices 69 and do online shopping 65 however in contrast previous research showed that unlike other icts the intention to learn internet banking among older adults is not significantly impacted by social influence since users tend to access banking services alone considering security issues 11130 one potential reason for this difference might be that the new generation of digital banking services offers more social opportunities such as sending digital money to their social circles as financial and emotional support or seeing others pay for goods with a single contactless tap that was unavailable decades ago as our participants mentioned they were motivated to learn digital banking after they felt envy when seeing people around them use it or received electronic money transferred from others although social influence mostly played a positive role in increasing the adoption of digital banking among older adults few participants also mentioned that their family members tried to steer them away from digital banking to avoid potential financial loss this raises an open question of how to help older adults adopt digital banking while minimizing potential financial loss in general our participants felt that they might be slow in learning or need some help along the way just as the previous research pointed out 25507988108110129 but they believed they could still do it they also felt proud of being able to use digital banking challenges in using digital banking we discuss design considerations to address the challenges older adults encounter when using digital banking 541 apprelated challenges we uncovered four types of apprelated challenges ambiguous affordance low information scent insufficient error recovery support and lack of feedback or confirmation the first two challenges were also found in a recent study about older adults using digital maps 129 the common challenges shared across drastically different apps suggest that mobile app designs suffer from common design flaws for older adults furthermore modern app designs also tend to use icons to indicate functions 9 although such designs can reduce text our study suggests that iconbased designs may lead to ambiguous affordance issues instead of just focusing on solving a particular type of app issue we as a community should conduct more research to carefully scrutinize whether general mobile app design practices and guidelines are suitable for older adults and more importantly how they might need to be adapted based on older adults experiences toward this goal we discuss some potential design solutions minimize the number of visual elements per screen when reviewing digital banking apps we noticed that they tended to show many options on one screen although app designers often use different font sizes and colors to provide grouping and hierarchical information to distinguish different options which is a good practice in general our study and other ones together provide evidence that some ui elements with less visual salience would likely go unnoticed if there are too many visual elements as a result reducing the number of visual elements per screen would likely increase the chance of each element being noticed by older adults what functions should be shown on the screen previous research shows that older adults might prefer a multilayered interface design which provides reduced functions for initial learning and then progressively increases the interface complexity over a fullfunction interface 61 however one challenge with multilayered interface design is how to present additional functions to older adults one common approach is to hide them in deeper layers which will result in a deep and narrow design this raises the discoverability issue indeed our participants mentioned that they did not realize the existence of certain functions that required many steps to reach it remains an open question of how to balance the visual salience and discoverability of a function in mobile apps understand older adults interpretations of common icons one cause of the ambiguous affordance issue was the misinterpretation of graphical icons for example although a triangle icon might be interpreted as clickable by young adults our participants did not always perceive it as clickable indeed berget g and sandnes fe found that icons were not universally known by all and age had a positive correlation on the recognition of the aged icons vs timeless icons 39 older adults were found to have more problems using existing mobile device icons than younger adults 62 a recent study also showed that older adults might misinterpret icons and interactive elements in online visualizations 35 furthermore rock et al summarized that four icon characteristicssemantically close meaning familiar labeled and concrete improved its usability for older adults and they suggested allowing users to choose an icon from a set of potentially suitable icons 62 similar to icons we also found misinterpretations of mobile app ui elements understanding how older adults perceive icons or common mobile app ui elements would provide insights for app designers to design ones that match older adults expectations thus future work should systematically explore older adults interpretation of banking icons or uis in addition to universal icons icons with a specific cultural element can also be designed for older adults living in that culture explore interactive intelligent agents to assist older adults one way to combat the low information scent and insufficient error recovery support is to allow older adults to ask questions when they are confused as voicebased intelligent assistants continue being improved researchers began to investigate their potential in assisting older adults 51104 indeed our participants also expressed the need to ask others when learning digital banking thus it is worth investigating whether and how to design voicebased intelligent assistants to help older adults overcome challenges when using mobile apps when they have no idea what to do with an interface or need to recover from an error toward this goal older adults thinkaloud verbalization and voice features can be used to build ai models to detect when they encounter problems 323336 furthermore bank employees mentioned that some pioneer banks started to add voice interaction into mobile banking apps however for older adults with poor hearing the devices could not automatically increase their voice to an appropriate level and react like a real bank employee future work should explore how to design voice assistants that are not only able to detect the problems older adults encounter but also interact with them like a real bank employee combination of human support and advanced technologies in addition to the aforementioned automatic voice assistants with intelligence and voicebased interfaces we can also consider combining automatic features with human support to help older adults for example when older adults first learn to use digital banking it might be more helpful for them to interact with a real remote bank teller who can empathize better than a pure automatic agent recent technologies such as virtual and augmented reality might also allow older adults to interact with a live remote bank teller through embodied avatars and shared visual cues moreover future research could explore ways to design features that enable helpgivers to draw visual guidance on older adults phones to support them in conducting banking transactions and even support them to perform trialanderror which is effective for learning new technologies but is often challenging for older adults to do 3435 another approach is to design a remote collaborative tool that allows helpgivers to demonstrate how to complete a banking task with interactive guidance for older adults 542 userrelated challenges we propose the following design considerations to address three types of userrelated challenges anxiety low perceived selfefficacy and memory concerns increase older adults understanding of digital banking with social help the main causes for anxiety were related to the abstraction trustworthiness and security and privacy concerns of digital banking platforms previous research found that older adults are concerned about security and privacy issues when they access digital technology such as smartphones and health monitor systems and they also experience challenges with managing online security behaviors and privacy settings on their own more recently the social support approach provided by older adults social networks especially closeties either family or peer friends has been found effective to help older adults manage the security and privacy of smartphones 5676116 compared to general smartphone usage digital banking is more sensitive to older adults with possible economic risks and privacy leaks which may lead older adults to feel more anxious while using thus more research is warranted to investigate ways to better inform older adults how digital banking works help them debunk false impressions and build confidence with social support while considering how to avoid invasion of privacy during the support in the meantime banking entities should also pay more attention to security issues and further improve the mechanism of vulnerability patching 18 to fundamentally alleviate older adults anxiety about digital banking platforms integrate the feeling of companionship into the design of digital banking on the other hand concerns about digital bankings security and privacy were not unique to older adults younger adults were also shown to worry about the perceived risk and privacy of digital banking services 4657 one potential reason was that online services lack physically present security personnel as in physical banks 55 this suggests the importance of the companionship of a trustworthy person for creating a safety feeling of digital banking platforms this was echoed by both the fact that older adults would rather wait a long time to receive assistance from bank employees 48 and in bank employees observations that older adults felt safe when talking to them and receiving printed receipts of the transactions the sympathy that helps givers express when interacting with older adults is what current digital services lack as s6 articulated machines are not as smart as bank employees but more importantly not as sympathetic as them however bank employee participants felt that it was challenging to keep being sympathetic and patient when they had too many customers waiting to be served one potential future direction perhaps is to integrate companionship and sympathy into the design of voicebased assistants to not only offer help but also express sympathy and companionship increase older adults perceived selfefficacy our study found that the main causes for low perceived selfefficacy were being afraid of making mistakes and lack of confidence in their literacy level and their declining physical conditions one common underlying factor was the potential financial loss associated with mistakes or misoperation this suggested that older adults might be more sensitive to loss aversion 49 when dealing with digital banking platforms this was evident in the approaches participants took to minimize their potential financial loss set an upper limit for the amount of money put in digital banking platforms bind a dedicated nonprimary bank account with the digital banking platforms practice with a small amount of money future work should investigate ways to help older adults cope with loss aversion by boosting their confidence when using digital banking platforms one potential approach is to deliver multimodel confirmation instead of just visual confirmation current mobile app confirmation design heavily depends on visual feedback however older adults often have declining eyesight and may not be sensitive to all sorts of visual feedback instead the app could deliver the confirmation in multiple channels for example by popping up a box and reading the confirmation out 59 another approach is to design better error recovery mechanisms current errorrecovery mechanisms often require users to accurately press a series of buttons to return to a previous step however it is not uncommon for older adults to encounter touchrelated motor issues 249697 such as tapping and swiping thus touchbased error recovery mechanisms might even lead to more errors along the way furthermore it is also challenging for older adults to figure out which step they should backtrack to this raises an open question of how best to help older adults recover from an error one possible direction is to leverage artificial intelligence to infer the step where older adults start to deviate from a correct completion path and later guide them to backtrack to the step lastly our findings revealed common memory concerns such as forgetting passwords or to do a required action there is a body of literature investigating ways to alleviate these memory issues such as designing more memorable authentication mechanisms and reminder systems moreover participants were also afraid of forgetting the steps of completing a bank transaction and wrote the steps down in a notebook however writing the steps down is not a scalable approach to learning one potential solution is to leverage ai technology to learn the steps for completing a task and alleviate older adults from needing to remember the steps for example li et al showed an approach for the mobile app to learn from the user how to complete a task and then automate the process for the user for the same and even other similar tasks 64 future work could investigate similar approaches to help older adults complete tasks without needing them to remember the exact steps limitations and future work our study presents a qualitative understanding of why and how older adults in china use both physical and digital banking platforms how they learn to use digital banking platforms and the challenges that they encounter although our study included older adults from rural areas the majority of the participants lived in middleand bigsized cities as the general technology development and the availability of digital banking services might differ in differentsized cities our findings might not reflect the banking practices and challenges of older adults living in regions with different levels of economical development china has been experiencing one of the fastest growth in electronic transactions thus older adults in china might have felt stronger peer pressure to adopt digital banking compared to countries where digital banking is yet to gain popularity moreover the culture household income the occupational and educational background of older adults may also affect their mindsets about money and their financial management strategies future work should investigate older adults banking practices in different countries to better understand cultural impacts and derive common and unique challenges furthermore our study did not compare the user experience of different banking apps a controlled experiment with older adults using different banking apps would be able to understand the pros and cons of different app designs last but not least our study shows that older adults are not helpless but instead are quite willing to learn new digital banking technologies and apply their accumulated experiences and knowledge to come up with creative solutions before seeking help from someone whom they trust inspired by this finding and the advocate for positive aging 4053 we argue that we should design interactive learning approaches with older adults so that they could play a more active and leading role in exploring new technological solutions that still allow them to gain support from their close ties this could also be a great opportunity to foster a stronger intergenerational bind which might potentially reduce ageism 71

managing finances is crucial for older adults who are retired and may rely on savings to ensure their lives quality as digital banking platforms eg mobile apps electronic payment gradually replace physical ones it is critical to understand how they adapt to digital banking and the potential frictions they experience we conducted semistructured interviews with 16 older adults in china where the aging population is the largest and digital banking grows fast we also interviewed bank employees to gain complementary perspectives of these help givers our findings show that older adults used both physical and digital platforms as an ecosystem based on perceived pros and cons perceived usefulness selfconfidence and social influence were key motivators for learning digital banking they experienced apprelated eg insufficient errorrecovery support and userrelated challenges eg trust security and privacy concerns low perceived selfefficacy and developed coping strategies we discuss design considerations to improve their banking experiences ccs concepts • humancentered computing → accessibility • social and professional topics → seniors

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background rri and synthetic biology brissynbio is one of six uk epsrcbbsrcfunded research centres in synthetic biology 1 using tools such as crisprcas9 12 brissynbio researchers work to develop synthetic biology to do various things for example to modify human red blood cells cellular mitochondria or the dna recombination machinery of crop plants framed within a responsible research and innovation agenda brissynbio research must also ask to what extent the laboratory research agenda andor laboratory practices are shaped by ethical concerns public engagement or policy debates surrounding the future use of gene editing tools in medicine fundamental research and food crops such as wheat one way in which brissynbio has engaged with rri is by deliberately using an arts theme in this article i will very briefly introduce rri synthetic biology and artscience collaboration so that i can describe how artscience projects might engage with science policy goals like research responsibility and provide suggestions for practice based on analysed empirical material from interviews and ethnography during my time as a participant at the centre responsible research and innovation responsible research and innovation is a more recent policy term to describe a changing approach to the relationship between science and society in a changing research economy in the previous linear model the corporate research laboratory had the expected role of translating university research into something economically useful in the postfordist research economy the corporate research lab has largely disappeared 3 universities are expected to take up this slack having a more proactive role in regional economies 3 recent policy emphasis on competitive innovation economies has been paired with calls for rri the previous moral contract between scientists and society could have been summarized as pay for basic science and leave scientists alone and this will in the long run generate applications of benefit to the economy and society but this previous rhetoric regime justifying funding decisionmaking and research direction is now largely being replaced a new grand societal challenges model suggests research should be useful to society and address grand challenges in society andor global society one reason for this has been a longterm recognition of the collingridge dilemma that with new technologies we have not enough knowledge about their environmental health social and safety impacts to effectively regulate them but by the time we do have enough knowledge to do so the technologies are well established and therefore difficult and expensive to change 4 2 lastly there is a growing recognition that what begins in the lab becomes a generalized product technique or knowledge outside the lab an awareness of how the research process itself is the beginning of any outcomes and that choices in the laboratory may have longer term consequences that are difficult and expensive to correct at a later date when researchgenerated industrial processes are in place and the innovation has become embedded in existing social and technological systems at that point it becomes very costly to make changes even if we can now understand and justify what could be made better or at the very least less harmful therefore a question which rri attempts to address is how we might pull society and its concerns and needs into the lab earlier so that what comes out of the lab is already better integrated to the needs of communities that rri emphasizes not just responsible innovation but also responsible research indicates the break with the old linear model where scientific research was considered independent of its consequences which were thought to only accrue later in an applications development phase an important early policy framing for responsible research and innovation defines it as an interactive process by which societal actors and innovators become mutually responsive to each other with a view to the acceptability sustainability and societal desirability of the innovation process 9 there are several models for integrating social societal concerns into research agendas for example the eu model has delineated a list of policy areas to address for institutional change 3 i will here focus on the socalled area model promoted in the uk by the environmental and physical sciences research council successful at explaining the concept because it seems to encapsulate the complexity in a memorable way 4 area stands for anticipate reflect engage and act the qualities of being anticipatory reflexive and inclusive are to be integrated into research agenda while this does not guarantee consensus from all the various parties it is hoped that one outcome will be changed research trajectories which begin to better reflect societal concerns i have here simplified the history and explanation of the term rri which is undoubtably interconnected with several other similar concepts and has been taken up by different communities with different goals for slightly different reasons the commercial recognition that design of technology matters in how potential customers take up products and the need for companies to be trusted by their customers has made responsible innovation a recognizable term in the commercial sector an existing and evolving discourse within the social sciences humanities and science policy has included elsielsavarious types of technology assessment which have all contributed to our academic understanding of rri 5 although it is not often acknowledged the greater willingness to consider rri might also be part of a desire to avoid previous political disputes during or after the introduction of new technology previous controversy around gm crops is one example there are many claims on what responsible might mean the word responsible is a quite generic term thus allowing different persons or institutions to take up rri in different ways in some ways rri is a fraught termquite politically neutral in a realm where there are potentially conflicting commercial and civil society interests in how technological innovation establishes the framework for what is and is not possible in society how decisions are made and how resources are distributed ie the basis for politics in a technological society is the technical infrastructure of society 22 it is also worth considering fig 1 collingridge dilemma 8 whether or not there are implicit claims in the word innovation which is part of the term rri recent policy emphasis on competitive innovation economies within a neoliberal economic growth agenda has been paired with calls for rri in contrast some academics have asked why not choose responsible research and stagnation in a world where innovationdriven growth puts the economy on a collision course with the planetary boundaries 23 the practical application of rri requires knowledge production to be anticipatory inclusive reflexive and mutually responsive 921 as well as integrative 21 aicardi et al 24 of all of these aspects within a research and ethics work programme to be inclusive is also to develop relations with stakeholders and publics outside of the academy and thus requires more than just interdisciplinarity between researchers it needs the development of crosssectoral sensibilities like interdisciplinarity crosssectoral exchange also requires attention to the differing interests and common practices of communities with different purposes but if anything the challenges of crosssectoral exchange are more diverse how do we integrate these different types of knowledge a first step in this process is interdisciplinary cooperation between expert academic fields cooperation between different epistemic cultures 25 presents a number of challenges for different disciplines what constitutes a valid research question and the type of evidence required to answer that question may vary because of this how resources are allocated and what individual researchers must do to progress in their career may be different even scientific terminology that sounds the same may be applied very differently between disciplines having in practice effectively different operational definitions for the same term interdisciplinarity may require additional resources and time to bridge these gaps with these greater differences collaborative projects often require greater time for trust to develop between parties shortterm projects may fail because of this but the task of putting society in the lab suggests thinking a little bit further than just the challenges of interdisciplinarity interdisciplinarity is cooperation between academic disciplines within the academic sector crosssectoral cooperation is cooperation between different sectors attention to crosssectoral differences matters because just as there are different incentive structures and interests in what counts as knowledge between disciplines which complicate cooperation so also there are entirely different goals or even values between sectors while a great deal has been made of interdisciplinarity in research less attention has been dedicated to the crosssectoral requirements of research that wants to be responsive to societal concerns desires and needs i want to turn in the next section to one proposed aspect of cooperation which lies somewhere between the interdisciplinary and the cross sectoral that of artscience collaborations and what role they might have in an rri programme for a synthetic biology research centre but first it is worth noting what synthetic biology is and some of the connotative similarities which it might have with performance in art especially when synthetic biology is considered as an action where its own definition is at stake new biology molecular biology includes laboratory practices to isolate and work with cellular dna the genetic material that directs protein construction in the cell and thus in part directs the development of living matter in the cell or the larger organism bioinformatics is the use of computer analysis to identify patterns and useful information with dna information abstracted from the cell or the organism by molecular biology techniques such as pcr 26 the idea that dna can be extracted analysed understood manipulated and reinserted into the organism to create different organizations of protein and therefore different forms of life is key to the concept of synthetic biology thought of as a purely epistemological practice synthetic biology is the manipulation or even synthetic reformulation of life 6 so as to understand how biology works however synthetic biology is most often thought of as an engineering practice for biotechnology applications by manipulating the metabolic pathway of a onecelled microorganism to generate a useful output a cell that takes in a feedstock and outputs an organic molecule of some industrial pharmaceutical or food engineering use applications to multicellular organisms are also being considered in some of the research at brissynbio and elsewhere a group of early starters in the field molecular biologistsbioinformaticians at a few important institutions have demonstrated in the laboratory proofofprinciple evidence of the synthetic biology concept and promoted the idea more broadly including to science policy actors funders and commercial investment actors with promises of future application 27 as a concept synthetic biology invokes several interdisciplinarities but also stands at the crosssectoral boundary between the university and entrepreneurial biotechnology enterprise the question remains whether the concept translates well to ordinary biologists further from this core of synthetic biology researchers institutional resources and knowhow the attempt to formulate synthetic biology as an academic research discipline or subdiscipline with a role identity for those who practice synthetic biology is an important aspect of resourcing such work at the changing intersection of university research economies synthetic biology researchers would then have departments and positions to take forward their career academic journals to publish in and as a recognized discipline funding to initiate new research the performance of synthetic biology is fraught balmer et al 28 note some of the role identity difficulties of successfully performing oneself as a synthetic biologist and particularly the differences in this task for those in the core and at the periphery of a field of social action to establish such a protodiscipline with less resources and less ability to define what counts as synthetic biology new researchers at the periphery of the discipline find it much harder 28 this is particularly true of phd students taking up the field as the hopeful beginning of their career in molecular biology while the ideas of synthetic biology might be available for researchers they must be enacted the biologist must claim resources for a synthetic biology research project and enact the claimed relations between a microorganism the manipulation of its metabolic pathway and a useful outcome then translation of tentative laboratory results to a successful industrial process within a viable business model and appropriate investment capital can be even more difficult thus the successful enactment of being a synthetic biologist exists at multiple levels of performance as role identity firstly as academic attempting to formulate synthetic biology as a discipline or subdiscipline and secondly as entrepreneur in the parallel attempt to enact the ambitious claims of early synthetic biologists within biotechnology innovation economies and thirdly a performance within microorganism metabolic economies the difficulties of this have made synthetic biology a challenging and potentially changeable protodiscipline to enact the original expectation of synthetic biology as an almost unlimited magic factory for anything largely failed to account for the costs of molecular metabolism cellular production even if one can successfully manipulate dna tame the promiscuous and changeable character of microorganisms to create a stable laboratory strain and translate that to a manageable industrial process is itself costly in several ways it turns out that molecular metabolism is most successfully performed with high energy feedstocks such as sugars which are commercially expensive in many cases more so than the proposed output in practice this has meant that many early career wouldbe synthetic biologists confront the threat of failure particularly if they depart from the academic career path to pursue an exciting but risky entrepreneurial role the previously openended economic narrative of the benefits of synthetic biology is now more likely to settle on a few plausible high value organic molecules such as flavourings or food additives applications in biomedicine or antibiotics research are still active concerns one brissynbio startup company is developing underwater industrial adhesive applications and has entered into research contracts with the british navy while synthetic biology is by no means exhausted or ending the initial preconceptions of the field may be adapting to experience and as balmer et al 28 note this is especially true in the relation between the core and the periphery of synthetic biology the concept of performing synthetic biology has an interesting resonance with performance in art which i will mention only briefly without attempting to draw too close a parallel that ones work depends on the successful performance of that work provides a parallel between the artist on the one hand and the early career molecular biologistaspiring synthetic biologist on the other the word performance has a wide variance of connotations a performance in theatre is not quite the same as a performance of music no one would say of a musician that they were not a musician because what they were doing was only performing music whereas an actor performing hamlet would be recognized as pretending to be so the performance of a social role is somewhere in between pretence and enactment at least initially as the social agent sets out to undertake a role for which they do not initially have the necessary credentials and recognition the phrase fake it til you make it is a common sense understanding of this in the social sciences symbolic interactionism and ethnomethodology have traced the path between a social theory of pretence and one of enactment actornetworks theory a later development of ethnomethodology 29 30 31 even takes up the role of materiality in enactment human enactment of a role is complicated by and imbricated in the materiality of the practice for example the molecular biology equipment computers and software for bioinformatics and not least the uncertain role of microorganisms who cannot always be performed exactly as hoped drawing a parallel to dance myers 32 has suggested that molecular biology is also a bodily performance indeed in my fieldwork i observed a senior molecular biologist instructing others and enquiring about their method of placing a tip on their pipette to tap down ones next disposable pipette tip was a routine activity to make sure it was properly attached but how one did this could vary would they use one tap or two would they have a specific rhythm or cadence what was being suggested was that each molecular biologist could do so in a specific way repeatedly that is to have a signature tap specifically chosen by themselves this was encouraging uptake of performance and a clear role identity with the body and its habitual gestures selfconsciously invoked in the performance of molecular biology while quite obviously performance is enactment consider also that there are many different ways that the body could do this and by drawing attention to this bodily performance you may become a better molecular biologist and thus the embodied action of molecular biology in this instance notes playfully a small nuance of performance or flourish somewhere between pretence and enactment i speculate it may have benefit in the overall quality of performance of molecular biology when the laboratory experimenter develops specificity in their manual method a more thoughtful pipette user is a better pipette user ie more likely to be a successful molecular biologist as i could wirness many tasks in molecular biology are very difficult to perform such as isolating genetic material using chemical reagents the pipette and the human hands with this brief interlude i will pass on to discussing artscience but the very small point i want to draw out of this incident is that bodily performance is an aspect of science which although present is rarely considered greatly by laboratory scientists who might more likely if asked define science as an epistemological enterprise neglecting its daily routines and more mundane activities however skilled and precise they must be bodily performance and role experimentation is also something explored in the arts for example theatre artscience exchange while artscience collaborations offer the potential to engage both publics and scientists and thus possess the potential to facilitate the desired mutual responsiveness between researchers institutional actors publics and various stakeholders there are potential challenges in effectively implementing collaborations as well as dangers in potentially instrumentalizing artistic work for science policy or innovation agendas artscience let us begin with a simple theoretical framework to guide how we might think about an artscience collaboration artscience collaborations are processes of exchange which require acknowledgement of and attention to artistic agendas as well as identification of and attention to aesthetic dimensions of scientific research the value of this twoway exchange process can be initially difficult for either party to perceive because of disciplinary preconceptions that members of either group may have either specific to their group or shared the very function of science as a successful disciplinary practice emphasizes disciplinary fidelity that biologists adhere to collectively understood rules of what constitute legitimate biological questions of interest and valid rules of evidence collection or experimental method to answer such questions is the basis of such disciplinary framework because they remain within it they retain access to disciplinary resources such as publication opportunities in biology journals research funding and career progression opportunities which become available to them exactly because their work fits the criteria for the biological sciences similarly while the arts are perhaps a broader set of fields than molecular biology there are here also given practices ways of looking at the world questions that seem of interest that are legitimate to ask as part of artistic research and questions that seem outside of the artistic remit generally scientists do not understand themselves to be doing work in aesthetics their emphasis instead being on determining natural laws empirically through hypothesis formation experiment and empirical verificationfalsification science is seen to be an epistemological project about the nature of the world whereas aesthetics as defined by seventeenth century philosopher alexander gottlieb baumgarten is a practice to organize or relate our sensory experience to a cognitive process 33 thus a simple example one might use rhetorically to explain aesthetics to a molecular biologist might be the role of perspective in italian renaissance painting the sensory experience of seeing perspective was translated in a formal way to twodimensional representation by creating specific rules for perspective 34 35 36 while today we might feel representation on a twodimensional surface of our visual experience of seeing in three dimensions seems quite natural this is in fact a learned way of seeing for thousands of years representation on twodimensional surfaces had been without the formal rules of a topology this new way of seeing pictures was initially a matter of artistic innovationa new way of relating the sensory experience to our cognition in the picture the ambassadors the artist holbein demonstrates humorously that he and other artists were wellaware of the slightly arbitrary nature of these rules by showing a topologically represented skull blurred by normal rules of representing threedimensional perspective on a twodimensional surface but available to a viewer of the portrait who sees it from an angle these slightly different rules of topology are called anamorphosis 37 this definition of aesthetics although commonly hidden by disciplinary prejudice is clearly present in the practice of science sensory perception must be organized to fit a cognitive procedure or choice in a variety of scientific experiments early biology with microscopes required the development of staining processes that allowed a cell to be seen and drawn certain aspects of the cell like the cell wall became visible in this process this certainly seems like a way of organizing sensory experience to a particular cognition or understanding likewise today a huge part of scientific papers published in peerreviewed journals is the organization of empirical evidence visually in figures for example a colourful graph or chart or selecting preparing a data photograph in some cases some choices must be made convention will not cover all circumstances and these choices are in part aesthetic choices about how to organize sensory experience in a way to make it fit to a cognition how a landscape painter makes sensory experience clear to an audience and how a scientific paper does so are very different with very different goals practices and conventions but both are to a lesser or greater extent and with different emphasis and not as their only purpose involved in some forms of activity that fit baumgartens definition of aesthetics aesthetics as a practice to organize or relate sensory experience to a cognitive process reciprocally the renaissance example of developing a perspective aesthetics demonstrates how epistemological processes aimed at understanding nature can also be a resource for developing new artistic practice so with this basic demonstration of how aesthetic and epistemological practices overlap i repeat the theoretical framework by which we might understand and potentially guide artscience collaboration this definition can be helpful in setting up assessing or guiding artscience collaborations artscience collaborations are processes of exchange which require acknowledgement of and attention to artistic agendas as well as identification of and attention to aesthetic dimensions of scientific research they are an exchange an exchange which can only be successful if neither art nor science is fully objectified by the other discipline when power differentials in collaborations remain unacknowledged it is often the scientists who are more likely to objectify or instrumentalize art for their own agenda a common objectification of artistic work within an artscience collaboration is to see it as a resource only for public engagement and at worst a propaganda tool for the laboratory researchers desire for public understanding of science grounded in a deficit model of the public that the public lack scientific understanding and that that is the only reason for some critique or disagreement the public might have with a scientific project there are institutional desires to be celebratory about the work that researchers do and about the value of science without critical engagement with the ways in which scientific research is imbricated in the social political economic environmental and cultural structures of society occasionally scientists will fear that the artistwriter painter will take up negative images of science influenced futures that the attempt to interest an audience will cater to the dystopian will the anticipatory aspect of imagining futures be plausible i have elsewhere written of plausibility in science fiction or socalled nearfuture fictions 38 i suggest the advantage of specifically identifying public engagementscience communication as a distinct aspect of such projects so that aesthetic scientific or social sciencephilosophical research agendas are not subsumed to the assumption that the primary or only value of artscience collaborations is as a form of fig 2 onepoint twopoint and threepoint perspective image from fig 3 a holbeins the ambassadors with anamorphic projection b lower portion of the painting viewed from an angle images from orgwikitheambassadors and moillusionscomtheambassadorsa3dpaintingbyhansholbein public engagement or science communication to mediate biological research community public messaging but the failings of scientists are not the only concern artists also can fail to take seriously the science james elkins argues that artists must work to understand what it is that science is trying to do on its own terms rather than simply take up imagery or some other product of scientific craft as an attempt to accomplish that for which an artist might use such material 39 taking science seriously does not mean being uncritical or taking science too seriously in addition to outright misunderstandings of scientific claims artists might also take up sensationalist portrayals of research results or uncritically promote scientific visions fictional futures or other ideas about the relevance of scientific research to parts of the world outside the promoters remit or expertise another common failure is art based on a superficial examination of sciences final outcomerather than examining fully the method and materiality that combine to become the epistemological claims 4041 borrowing from sociological studies of science and technology silvia casini suggests a method for artists to open up the black box8 of science if they desire to critically engage 41 art that helps us rethink the role of science in society examines the instruments material and craftbased knowledge construction of the scientific field that it seeks to explore comment on or utilize as a resource for new art practice another similar failing is to not see art as interpenetrated with the craft and culture of other spheres of the world most notably for the purposes of this essay science that art can have an experimental method and that science might contribute to rethinking artistic processes and experiment are important points that a successful artscience collaboration might bring out for artists in a successful exchange each party takes the exchange seriously either party may see the benefit of the collaboration as something different than what the other sees as the benefit different aspects of collaboration or its outcomes may be seen as useful to different parties problematically conceiving of artscience as an exchange can create expectations that more will be accomplished than might actually be achieved when setting expectations it is important to realize that while aspects of science contain aesthetic practice which might be useful for scientists to have a reflexive awareness of and aspects of art practice have roots in science mediated epistemologies of the world neither art nor science are primarily improved or succeed within their own disciplines through or because of these modes a collaboration may contribute something to each discipline but it may not contribute that much 9so i suggest two simple rules to guide an artscience collaboration that there is some benefit to each party however small and even if that is not necessarily a common benefit and that each take the other seriously artsciencerri so with this simple framework and set of rules let us consider artscience collaborations in relation to implementing a programme of responsible research and innovation as science policy goal is there a potential for artscience collaborations to be the basis for deliberative discussions on research agenda and direction how could artscience collaborations accomplish this using the simple area model it is easy that to see artscience projects can develop anticipatory frameworks that allow scientists and publics to explore how they feel about different potential future scenarios causing publics scientists to see their own location within one or another of the futures and thus also consider their own location relative to creatingpreventing potential futures encourages reflexivity immersive theatre is an example used at brissynbio and discussed below the ability of art to present material in accessible and interesting formats allows complex topics to be presented to a greater variety of people many of whom would simply leave to the experts discussions of science in traditional format weaving together an anticipatory reflexive and inclusive discussion may be a possibility for processbased art projects emphasizing participationbut ultimately integrating the outcome of such a process into the research agenda is then the responsibility of the research programme itself i began by describing a theoretical framework for artscience collaborations as an exchange an exchange which can only be successful if neither art nor science is fully objectified by the other discipline therefore although i do not discuss this point at length it goes almost without saying that an artscience project should not in a similar manner be instrumentalized or thought of instrumentally for the achievement of rri science policy objectives the social scientist the philosopher the embedded humanist the science policy agent the research officer the funder the scientific researcher whoever it is that facilitates or promotes genuinely the rri strand of scientific research must also take seriously the aesthetic and epistemological goals of an artscience project they must consider an artsciencerri triangle artsciencerri collaborations must consider the interests of all parties in the exchange and take seriously in equal measure the epistemological aesthetic and reflexive purchase of such an exchange empirical results the responsible research and innovation component of brissynbio was to be organized as a crosscutting thematic strand of the overall project this strand was overviewed by a principle investigator and lead by a director of rri both of whom came from the university of the west of england bristol while the overwhelming majority of the synthetic biology project teams were from the life sciences and chemistry at the university of bristol when i joined there were already a number of activities in place for the rri theme the week i arrived an exhibition of a half dozen artists commissioned to do work on a synthetic biology theme held an opening in a popup gallery in the old market neighbourhood of bristol researchers from the synthetic biology centre came to see it two ethics of case studies were already in place by myself various events organized by the rri theme had already happened such as a synthetic biology in society blog and a large open public discussion on synthetic biology 10 synthetic biology phd students within their training programme had time dedicated to ethics and society topics which the brissynbio rri team helped deliver there were also social sciences and philosophy phd students undertaking research on society philosophy and ethics issues at brissynbio the second brissynbio annual conference unlike the first would include a keynote rri speaker an rri theatre event had already happened and as i noted with interest during my week of arrival people were very pleased with it a philosophy of synthetic biology conference was planned to happen in the works was an away day weekend in wales for early career researchers and phd students focused on rri and art the theme of responsible research and innovation was just beginning to flourish in the research centre over the course of the next two years more events would be organized including a conference bringing together social science and philosophy researchers in the uk working on the topic of rri in synthetic biology and contributions to national and international science governance consultations i point to the specific way that an interest in art seems to have become a useful format with which biologists at the centre could understand and try to fulfil their rri obligations the centre had chosen to organize rri work along a specific strategy and this emphasis on linking art to science had emerged why some scientists seemed to like it and it created a focus for rri responsibilities which might otherwise have seemed ethereal to the biologists an early project in theatre funded as part of the eu project synenergene had worked with the research centre the positive experience which came out of that early project seems to have encouraged this direction for the sake of brevity i will not be able to document all of the work but in line with the question of how artscience might be used as part of an rri program i will discuss just a few examples the initial theatre project some of the framing for artscience at the centre and phd student experience in relation to artscience and rri my fieldwork data was generated over two years of ethnography and includes two dozen interviews three of which i incorporate here where useful i also draw in ethnographic data from my ongoing participation in the cereal genomics lab in various research centre events and talks and from participation on brissynbio committees such as the public engagement committee importantly i have also been involved in other artscience projects and this provides me perspective with which to better assess the brissynbio engagement although my background experience and this larger body of empirical material informs the theoretical framework i provide i have chosen to illustrate this case by close reporting of a small selection of interviews in this way i hope to provide the reader a sampling of the detail of such a large project as perceived from different perspectives at the same time as providing the reader an overall framework by which to judge the empirical material for themselves in the way i have presented it it can loosely be seen as before during and after a seminal event but it is only a sampling of overall rri activity at the centre only some of which i was able to collect data on and only some of that data was relevant to artscience collaboration 11interview project framing the requirement that the molecular biologists engage in responsible research and innovation was an early mystery for them a more senior scientist involved in the leadership team at brissynbio explained to me that they had worked on the synthetic biology components network a project leading up to the funding application for brissynbio this project had also had an ethics and society component of this my informant said we worked to understand it how could we do this who were the key players the rri strategy of the centre was driven by those recruited to lead this theme a sociologist and philosopher respectively there were three specific case studies and various centrewide activities primarily focused around early career researchers my interviewee explained to me that there were some early challenges in developing the ethics and society component of the programme it took a long time to find a common language between life scientists philosophers and social scientists there was at times resistance to rri from some synthetic biologists and more so from senior or more established individuals considering all the other challenges that synthetic biology as a science enterprise and role performance already presented the additional work in a different and perhaps to some seemingly offtopic direction may not be what all senior researchers want to be doing there was also the threat of academic overload …with everyone expected to do more and more and more and speak more and more different languages… we wanted to protect early career researchers from being pulled in too many directions at once according to my interviewee the creative role of art in the centre had not been strategic it was never written down in a document it had emerged in an organic way from the process of interacting with artists during the first two years of the centre for example an artist worked with one of the case studies to explore blood culture and the aesthetics of blood in art receiving multiple rounds of funding the bristol centre for public engagement who had been involved in supporting brissynbio at an early stage brought several eu projects providing additional funding such as synenergene 12 and perform 13 looking at public engagement around synthetic biology and exploring the arts as a tool in public engagement the responsibility of the bristol participants in the 20 partner project synenergene was to explore and conduct public engagement through theatre this seems to have had a significant impact …we obviously always thought that well be able to count yknow the number of people that came and the amount of schools that were involved but what we absolutely hadnt foreseen was that the process of writing this piece of theatre that we did our best to set up in such a way that it would draw on many people across brissynbio we hadnt foreseen that that process would be so empowering for the people that were part of it the process of writing the piece of theatre was described as empowering involving 18 months of interactive scriptwriting working with a group of early career researchers the directors and scriptwriter interacted with all brissynbio research groups and came back with questions there was time and permission to really think about these issues to have that conversation this early success helped a group of scientists who had been wrestling with how they would do rri at their centre come to a better understanding of what they might accomplish interview performing artist when i spoke with one of the directors from the theatre group which brought together the production he discussed this careful interactive process while his background in science was not strong he clearly indicated that their first step in the process was to engage with the synthetic biology research at hand one had to have curiosity and the ability to listen well and translate it back he informed me they had been approached by the public engagement unit at the university of bristol had been given a few parameters for example the target age group for the audience was secondary school children but largely there was little guidance given them interestingly he saw the distinction between art and science as artificial particularly when collaborating in an open interactive process that both art track and science track school children were recruited as an audience he saw as positive an early unravelling of the distinction the play was considered very successful and recommissioned for a second run this time aimed at a more general audience what we bring to the table what we are experts in is storytelling having a narrative arc that will engage and include a whole lot of different perspectives and come across to an audience from a whole diverse range of backgrounds in an accessible and engaging way storytelling is character understanding people we look a lot at different futurological scenarios from working with science we might try to imagine where it could be in twenty thirty fifty a hundred yearstime but then we think about the people that will inhabit those worlds who fundamentally from a human psychic perspective might not fundamentally have changed so to think about people from different parts of society different ages and backgrounds might react to scientific development although he felt it was very important to have as much accuracy as they could feeding into the process and thus working with scientists was the only way his theatre group would even consider doing such a piece he was clear that they were not pretending to be predicting the future the role of thinking about the future was less about emphasizing a plausible future scenario than creating a conversation about how humans interact with one another and why this might be relevant for doing science now in a way that might better acknowledge those interactions the focus was on building a process rather than a product the emphasis was on the journey and the legacy rather than the performances themselves there were workshops and conversations with different groups in brissynbio they wanted to build a collaborative process there was a first draft public reading of the play to get feedback the rehearsal draft was open and people could come and comment they asked questions and encouraged people to think in different ways perhaps not to the degree that we were but the scientists were also coauthors of the piece he informed me of the play there were some challenges initially some had thought of how the arts could be used as a mouthpiece for science other researchers could not be involved because of limited time perhaps others thought it would not accomplish much or were not initially sure if it could but this efficacy later became apparent in the process of building interaction and doing theatre exercises as much as possible we wanted them to see the potential of theatre we invited them into our world not just to talk about it but also to experience performance the molecular biologists were given to experience themselves as performers the subject of the play invincible was chosen deliberately to be controversial gene editing within the human being to remove a potential genetic mental health problem the characters were three generations of women and the grandmother had edited the mother such that the daughter was now different changed in such a way that a presumed mental health problem was deemed less likely to occur the play had a vicarious atmosphereset within a domestic apartment the audience came into an ordinary house whose kitchenliving room was where all the action happened interaction with the audience was deliberate between each scene the audience were asked questions and a scientist in a white coat came out with a camera to make a record of the vote of this the interviewee said they were working not just to be a mouthpiece it was very difficult to articulate questions that did not lead the audience in anyway my informant explained that they wanted to sit in the middle on the fence they sought out questions which could get a 50 50 response from the audience in this way the provocation could continue at the end there was a questions and answers session with representatives from brissynbio the scientists also asked questions of the audience there was a deliberate attempt to reverse roles and upset the usual oneway conversations between scientific experts and laypeople in this way it was hoped that everyone could be considered an expert in what future was desirable for society a film of the production was made creating a documentary of the process and leaving a legacy of the play invincible 14 the event influenced brissynbio in their early period of wrestling with what was rri and how to engage with it but it also influenced the theatre group this had been their first longer engagement with an academic research centre but since then they have been involved in other artscience collaborations and elaborated further the process which they initiated first with brissynbio 15 when asked if policy got in the way 16 my interviewees expressed that they did not feel inhibited or directed they felt they had a clear idea from the start of the job what the ambitions of those who commissioned t he project were and this is why they took it if anything they would have preferred to widen the audience to throw it more open and indeed when the very successful performance was recommissioned the target audience was broader not just school kids interview artscience and the early career researcher perform 17 funded the rri retreat and by that time the leaders were quite deliberate about the artsstrategy because of the influence of the learning from the theatre process i interviewed two brissynbio members who were in their second and fourth year respectively of their phd they had come to synthetic biology from chemistry and from chemical engineering respectively both had received brief introductions to rri before during their centre for doctoral training sessions 18 the earlier cdt cohort had received slightly more training about a week during their coursework and with a variety of speakers from different perspectives both had volunteered for the rri retreat they wanted to think more about the rri aspects of their work the retreat was held in a victorian mansion very much off the beaten track in the wye valley in wales down idyllic countryside lanes and over cattle grids it was seen by them as location suitable for reflection one noted how quiet it was relative to the city over the course of three days the facilitators brought 15 participants through a series of games creative exercises and discussions there wasnt a specific curriculum in relation to rri but instead it was discussed more generally in creative processes such as painting role playing making clay sculptures a walk through nature collecting 14 15 16 the reason this question was important for the framework i had developed is discussed in the discussion of findings section below particularly in the discussion of fig 5 17 18 a bbsrcepsrc funded centre for doctoral training in synthetic biology was inclusive of brissynbio phd students and also two other universities fig 4 immersive theatre the audience in the kitchen of the action image from youtubecomwatchv71k6h3 wg1i8 items to attach to a cardboard nature crown singing or choosing from a table full of trinkets and then discussing the object in relation to themselves and why they were there in one exercise participants stood along a line based on how much they agreed or disagreed with a statement for example to what extent science was objective or subjective as a group most felt that science had significant subjective elements in another exercise they wrote japanese renega poems collectively each one beginning a line of poetry and passing their piece of paper left to be continued by the next person a professional singer composed a song from topics in an rri discussion where participants had made statements and then discussed identifying hotspots in the discussion where there might be disagreement or where a topic was considered important participants were taught to sing these lyrics in multipart harmony and with rounds at the end of the three days a number of summingup discussions happened and participants were asked what they would take away from the weekend what they felt they had learned my interviewees noted that the weekend was very relaxing despite being very intense in a certain way they expressed positive feelings about the event by being outside of their normal laboratory environment with a lot of time to talk and reflect they felt that they were able to consider the importance of the topic to themselves in a way not normally possible in the day to day activities of a research career while it was great to have values and big ideas everyday laboratory life did not always allow these to be enacted so as one interviewee said he would be looking for those opportunities when they did become available reflecting and not making brash decisions he wasnt sure this would change anything he did immediately but he would be reflecting on the bigger issues whichever career choice he made academic or industry both students who i interviewed had slightly different feelings of being disillusioned with sciencethe more senior had looked more closely and rethought science as part of the earlier more substantial week of training in rri he had previously thought of science as the truth but now thought in a more complicated way about science he noted that it had a history of being associated with revenue generation for capitalism since the industrial revolution as an engineer finding better solutions was what he felt was most important and in some cases technologies presented as solutions were suboptimaltechnologies made for the sake of it he felt the retreat gave him an opportunity to think through his ideas and made him more confident about speaking about science the other student experienced some disillusionment as a result of the retreatthis had made him feel sad when he went awaythat at the beginning of his phd he had had what he described as a naive belief that science would provide the solutionsand now he felt that more realistically science could be useful in some ways but it was not always a solution for every problem he now thought about what technology was how it impacts upon society and to what extent one could predict this impact he spoke of undergoing thought about the development of science and technology one interviewee remembered what one of the artist facilitators had said that they had learned during the retreat research scientists are left with this responsibility and there should be stuff resources in place to help them both students commented on the interest and value of working with these other modes of learning that their curriculum since gcse 19 had been almost entirely science based and that this was unfortunate they felt this resonates with remarks by the theatre maker who noted the inclusion of both art track and science track students enabled them to see that art could be an unusual starting point to discuss science or that science could be a subject for artful performance the interviewees felt that the science and art distinction was somewhat artificial that science was a creative process one example was being able to write well the activities of the retreat had had effects changing operating patterns of how our brains work breaking down barriers creating mental fluidity it was very relevant to use art as a way of exploring science every scientist could benefit although it does not necessarily need to be about exploring rri he added in this last statement he makes a distinction between what i would call an artscience collaboration and an artsciencerri collaboration it is perhaps a measure of the success of the process of that although artscience was used as a method to talk about rri the process in its participants estimation was not limited to that discussion of findings one measure of rri process efficacy is to what extent the research agenda changes as a result of such processes the rri retreat group was a smaller selfselected group of scientists from the overall cohort their influence on the overall cohort or the longterm research agenda of the centre is unknown the theatre project brought in a finite audience and the audience influence on the research agenda of the centre is unknown since the research direction is set well in advance through funding proposals with longterm deliverables any changes in research agenda could only emerge gradually measurable across a larger interval than the period of this empirical research but the selfidentified influence on some individuals within brissynbio seems clear the ability of the artscience process to invoke conversations that were anticipatory reflexive and inclusive within the researcher community seems also evident the artscience theme had not been organized strategically but instead emerged organically even if the artist facilitators could invoke meaningful integration of different conversations it is the researcher community that is ultimately responsible for taking appropriate action as a result of the process this research documents similar types of resistance to rri that other research into rri elsewhere has found lack of time lack of belief that it will be relevant and resistance to interdisciplinarity but institutionally brissynbio seems to have been committed to fulfilling their obligations to rri although how to do so was initially unclear to them this seems to be where artscience not originally a specific strategic choice emerged as part of brissynbios approach possibly because this emerged organically rather than strategically there seems little evidence in this case that a science policyrri agenda was problematic within an artsciencerri triangle with a preplanned use of artscience directly mapped onto rri objectives this concern might in principle still be something to which a selfreflexive rri team would need to be attentive the reason i felt it was important to ask the artists about the impact of a science policyrri agenda upon themselves is explained thus artscience projects are modelled as interdisciplinary exchange which can be judged successful if each discipline takes the other seriously in my previous experience these artscience projects had been set up or facilitated by myself andor other social scientists 20 we had begun to think reflexively about our own role in the process therefore we felt in an artscience social science collaboration we should be asking for feedback on whether we were thought to be taking our collaborators seriously in addition to directly doing social science research we were also agents of science policy emphasizing the responsible research agenda in fact the funding for the artscience projects came from this myself and my fellow social scientists had constructed an artscience rri triangle where rri was the facilitator as social scientists funded by science policy promoted rri we were agents of science policy therefore the important reflexive question was was science policy objectifying the art science collaboration for its own agenda other disciplinary interests could also be facilitators by using rri funding and therefore becoming agents of science policy by looking at our own role institutionally we had been able to see science policy as the larger facilitator in a general sense whereas specific disciplinary actors were the facilitators in the specific situation in our case social scientists and in the brissynbio case it would later become apparent to me that the performance artists themselves largely did the specific facilitation role even if science policy was the general facilitator of an artscience rri triangle because the bbsrc requires their funded biological researchers to commit a percentage of their time to public engagement work there were attempts to adapt rri to a public engagement agenda more so to fulfil bbsrc time requirements than any attempted research laboratory public relations exercise in the simplest way most biologists in my field work seem to experience rri as public engagement it is but a nuance that to a social scientist rri also encompasses futures work reflexivity that locates the researcher and the research project within the bigger picture and should feedback into the longterm research agenda when future decisions are taken on research direction the university of bristol public engagement team seems to have incorporated a more nuanced plastic definition of public engagement and thus they had the ability to support rri within brissynbio beginning with the idea that public engagement is twoway communication and continuing to other nuances like the anticipatoryreflexive aspect of rri noted in the area model in this case the use of the term public engagement did not have as much of an eclipsing effect on the other qualitative aspects of rri as i expected to find but distinguishing inclusive engagement as an aspect of rather than a synonym for a fully complete rri programme may still be potentially useful public engagement is also the rri component which forces a research programme to do more than interdisciplinarity it often requires crosssectoral interaction at least in the generic sense that publics are not entirely composed of other academic researchers and thus have different incentive structures and goals in this i note that the artscience theoretical framework that i proposed in the above sections is set within an interdisciplinarity framework this is in contrast to the empirical material i present where the success of the theatre facilitators was in part due to their existing crosssectoral status relative to the academic researchers they were a communitybased public engagement theatre company not art theorists or academic researchers although they did have their own method of experimentation and knowledge criteria their relation to brissynbio i would position as somewhere between cross sectoral and interdisciplinary it is important to remember that in principle rri must be cross sectoral because it seeks to engage stakeholders publics with a role in determining scientific research agendas based on societal needs conclusion here i have examined the potential for artscience collaborations to be the basis for deliberative discussions on research agendas and direction responsible research and innovation has become a science policy goal in synthetic biology and several other highprofile areas of scientific research while artscience collaborations offer the potential to engage both publics and scientists and thus possess the potential to facilitate the desired mutual responsiveness between researchers institutional actors publics and various stakeholders there are potential challenges in effectively implementing collaborations as well as dangers in potentially instrumentalizing artistic work for science policy or innovation agendas when power differentials in collaborations remain unacknowledged i have suggested artscience collaborations are processes of exchange which require acknowledgement of and attention to artistic agendas as well as identification of and attention to aesthetic dimensions of scientific research a common misunderstanding is the expectation that art can be used to promote a science agenda i have therefore suggested the advantage of specifically identifying public engagementscience communication as a distinct aspect of such projects so that aesthetic scientific or social sciencephilosophical research agendas are not subsumed to the assumption that the primary or only value of artscience collaborations is as a form of public engagement or science communication to mediate biological sciences research community public messages from the evidence of brissynbio there is a potential for artscience collaborations to be a basis for deliberative engagement with publics on research agendas and direction in some cases the mode of art makes consideration of difficult science less remote to nonscientific publics and can encourage a more inclusive engagement they can also encourage reflection by scientific researchers on their own practice and where it is situated within research economies stakeholder concerns and promissory discourses about the future benefits of synthetic biology as part of the practical implementation of such a project there is usually some facilitation or at least direction from agents responsible for or aware of the rri policy goals thus i have suggested it is useful to think of an artsciencerri triangle in suggesting this i encourage a more reflexive research agenda within the science and technology studies and science communication communitywhat is the rri researcherfacilitator role within science policy and the incentive structure that motivates it in the case presented here facilitation was in part performed by the artists themselves developing group processes were part of their specialty the public engagement office at the university set up the collaboration some of the rri theme team participated in the process and some orientation was given to the theatre group in their initial brief nevertheless what can be considered a useful process emerged artscience collaborations can take up many of the questions an rri process suggests are important the empirical evidence reviewed here supports the model i propose to guide our framing of artscience within an rri process but additionally points to the need to broaden the conception of and possible purposes or motivations of art for example in the case of crosssectoral collaboration with community engaged art we can see that the artists already had a clear engagement agenda and experience in developing reflexive processes with a community of nontheatre participants and this experience was applied to the sciencetheatre project thus whereas the very simplistic guidance model i have proposed here suggested we think of artscience as primarily interdisciplinary in this case of a communitybased theatre it is necessary to identify also the crosssectoral aspect of the collaboration there was an aesthetics research interest by the theatre group but perhaps more interestingly the emphasis of community theatre was more about inclusivity and engagement than aesthetic experimentation with bodily performance although clearly both were part of their work their emphasis was on the process of engaging social relations of a group and theatre was a means rather than clearly an end in itself the play was considered a biproduct of the process intended to be inclusive and reflexiveand in this particular case intended also to consider futures perhaps because of this philosophy of community theatre as engagement the troupe functioned as the rri facilitators themselves in such a way that this initial artscience project was successful as rri ie encouraged the anticipatory inclusive and reflexive discussions and provided a model for a research centre that was wrestling with how to understand and enact its rri requirement thus the centre through this initial process seems to have developed other artscience collaborations and enacted the rri strand of its obligations in this way as one of my brissynbio informants put it invincible was an immersive sitespecific theatre production that was one of our most important outputs from the whole of brissynbio it was public engagement it was responsible research and innovation it was reflexive it involved a huge number of early career researchers senior academics professional practitioners theatremakers and yknow the success of that endeavour unlocked a whole load of kindof strategic thinking about what rri is how we can do rri at bristol what the benefits are for all of the parties involved and i think thats really the point at which we realized the power of the arts in unlocking some of those questions for us open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as 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here i examine the potential for artscience collaborations to be the basis for deliberative discussions on research agendas and direction responsible research and innovation rri has become a science policy goal in synthetic biology and several other highprofile areas of scientific research while artscience collaborations offer the potential to engage both publics and scientists and thus possess the potential to facilitate the desired mutual responsiveness rené von schomberg between researchers institutional actors publics and various stakeholders there are potential challenges in effectively implementing collaborations as well as dangers in potentially instrumentalizing artistic work for science policy or innovation agendas when power differentials in collaborations remain unacknowledged artscience collaborations can be thought of as processes of exchange which require acknowledgement of and attention to artistic agendas how can science be a conceptual and material resource for new aesthetics work as well as identification of and attention to aesthetic dimensions of scientific research how are aesthetics and affective framings a part of a specific epistemological resource for scientific research i suggest the advantage of specifically identifying public engagementscience communication as a distinct aspect of such projects so that aesthetic scientific or social sciencephilosophical research agendas are not subsumed to the assumption that the primary or only value of artscience collaborations is as a form of public engagement or science communication to mediate biological research community public relations likewise there may be potential benefits of acknowledging an artsciencerri triangle as stepping stone to a more reflexive research agenda within the sts science communicationscience policy community using brissynbio an epsrcbbsrcfunded research centre in synthetic biology i will discuss the framing for artscience collaborations and practical implementation and make remarks on what happened there the empirical evidence reviewed here supports the model i propose but additionally points to the need to broaden the conception of and possible purposes or motivations for art for example in the case of crosssectoral collaboration with community engaged art

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introduction in recent years there has been strong interest in the use of telemedicine to deliver healthcare telemedicine in its broadest sense refers to the use of information and communication technologies in the delivery of health services at a distance 2 the use of telemedicine has surged during the covid19 pandemic due to the restriction of inperson interactions clinicians around the world have used different ictbased platforms including computers mobile phones and the internet to address some of the challenges faced by developing and developed countries in providing highquality accessible and costeffective health care services 3 4 5 one of the most notable advantages of telemedicine is increasing access to health care services for geographically dispersed disadvantaged and stigmatized populations 6 such as transgender people 78 transgender is generally defined as an umbrella term that describes persons whose gender identity gender expression or behaviors does not conform to that typically associated with the sex to which they were assigned at birth 9 the transgender population is incredibly diverse and the definition of transgender is culturally specific 10 transgender people may include individuals who undergo gender affirmation surgery andor receive genderrelated medical interventions like hormone therapy and who identify as having no gender more than one gender or alternative genders 11 for these reasons it is difficult to estimate the actual population of transgender people some previous epidemiological and clinicbased studies have estimated that between 01 and 2 of the population identified as being transgender or other forms of noncisgender identities 12 13 14 it is well documented in the literature that due to intersecting forms of social marginalization and legal exclusion transgender people are disproportionally affected by a wide range of human rights violations and adverse health outcomes 15 transgender people especially those who are from a minority ethnic group are disproportionately affected by genderbased hate crimes 16 minority stress research has shown that stressful events experienced by transgender people have made them more vulnerable to mental health problems such as depression anxiety and suicidal ideation 17 18 19 a lack of support systems in the society for transgender people can also contribute to their higher risk for substance misuses hiv and other sexually transmissible infections 17 20 21 22 despite the increasing social acceptance of sexual and gender diversity in various parts of the world transgender people often experience barriers to accessing adequate healthcare 23 24 25 26 some major barriers that impede transgender peoples access to healthcare include discrimination in healthcare settings a shortage of gender care specialists a lack of adequate health insurance poverty and societal stigma 27 28 29 30 telemedicine can address some of these barriers for instance by offering transgender persons flexible safe private and comfortable ways to connect directly with transgender health specialists virtually thereby reducing the risk of discrimination experienced by transgender persons in the process of seeking healthcare 8 there is an incipient body of literature that advocates for the use of telemedicine to improve transgender peoples health outcomes studies have shown an increased acceptance of telemedicine among transgender people and clinicians 3132 and suggest that telemedicine can help promote hiv and sexually transmissible infection testing and care and improve psychosocial wellbeing by simplifying access to genderaffirming hormone therapy 73334 and perioperative care to individuals who undergo gender affirmative surgeries 35 some recent literature reviews on the use of digital and mobile health interventions have suggested that such interventions can effectively promote transgender youths health 3637 increase hiv testing rates 38 and deliver genderaffirming care 34 however these reviews either focused on younger transgender people or a particular health issue our article aims to extend the existing literature by exploring the types of ictbased health projectsprograms and interventions that have been used to deliver health services to transgender people of different ages and the concerns on using these interventions and ways to address these concerns methods protocol and research questions the review was guided by the frameworks developed by arksey omalley 39 and the prismascr checklist 40 the full protocol of this scoping review has been published elsewhere 41 the overarching research question that guided this review was what does the extant research say about the delivery and receipt of transgender health services through digital means in particular the following questions were explored 1 what ictbased health projectsprograms have been documented in the literature and how have these projectsprograms been used to deliver healthcare for transgender people 2 what is lacking in the current body of literature on ictbased health projectsprograms for transgender people 3 what are the concerns about effective ictbased health projectsprograms for transgender people and ways to address these concerns search strategy we initially searched pubmed cinahl and scopus for articles published in english with additional grey literature explored using google scholar and citation mining in may 2021 our multilingual team also performed a trial search in the chineselanguage ejournal database airti library in the early stage of the review which returned no relevant publications so we decided not to include the database search terms were developed iteratively through team meetings and trial searches and were grounded on three concepts telemedicine transgender persons and delivery of health care a supplementary search was conducted in january 2022 to identify more recent articles published between may and december 2021 the complete search strategy is presented in s1 file inclusion criteria publications were only included in the review if they 1 contained a detailed description of the development implementation or evaluation of a particular ictbased health projectprogram that used digital means to improve the delivery of healthcare for transgender individuals 2 successfully recruited or aimed to recruit transgender people or if transgender people were direct recipients of the serviceinterventionresearch project 3 were written in english selection of articles and data charting process duplicates were removed following the search article screening reviewing and data extraction tasks were shared by all members of the team first titles and abstracts of the nonduplicated articles were shared equally to screen out papers that did not meet the inclusion criteria the title and abstract of each article were reviewed by two members independently to minimise misclassification then the full text of the shortlisted articles was shared equally between team members and was reviewed rigorously to screen out any remaining papers that should be excluded data extraction was performed alongside fulltext article review and was guided by a predeveloped framework which consisted of publication information types of ict intervention used target audience total number of participants total number of transgender participants enablers and challenges described recommendations limitations of study methodology and key takeaways of the study during the review and data extraction process any doubts that arose in regard to the process were discussed in team meetings results overview of included articles the initial search yielded 790 nonduplicate articles after reviewing the titles and abstracts 704 articles were excluded leaving 86 for full text review at this stage 33 articles were included in the preliminary analysis the supplementary search in january 2022 yielded additional 176 articles after a further review a total of 14 additional articles met the inclusion criteria and were included in the final analysis all articles were published between 2014 and 2021 but more than half of these papers were published in or after 2020 the 47 articles covered a total of 39 ictbased projects of which the characteristics are summarised in table 1 majority of these projects 34 were conducted in north america while three projects were conducted in asia and one in australia over half of the projects had an experimental design the earliest project identified was conducted in 2010 80 but most began participant recruitment in or after 2015 among all projects 24 focused on improving hiv andor sexual health and 9 focused on genderaffirming care characteristics of participants in the literature among the 39 ictbased projects 15 specifically targeted transgender people there was one project which referred to transfemale and gendernonconforming people as msm 42 and another project 43 which categorised transgender as a sexual identity that was regarded as mutually exclusive with respect to being gay and bisexual some projects despite stating that transgender people were one of their target audiences only recruited a small number of transgender people or did not specify how many transgender people were reached or targeted among the projects that reported the transgender sample size a total of 5927 transgender people were recruited and among them 4338 received an ict intervention only 13 projects reported the age of transgender people recruited and 5 projects included transgender people under 18 the youngest and oldest participants recruited were documented as being 12 and 60 years old both being transgender patients of a health clinic 44 participants ethnic backgrounds followed the ethnic demographics of north america with most projects having recruited participants who were reported as blacklatinohispanic or white overview of ict interventions involved among the 39 ictbased projects a total of 8 major types of ict interventions were described these interventions included videoconferencing smartphone applications textmessaging social media telephone calls ecoaching selflearning platforms and econsultation platforms it is important to note that some of these interventions overlapped with each other and some projects used more than one ict intervention videoconferencing thirteen projects involved the use of videoconferencing technologies using platforms such as zoom google meet and doximity clinicians had conducted synchronous videochat or audioonly consultations to provide genderaffirming and other care such as hiv and sexual health care 324854 prep prescription 4883 preand posthiv test counselling 66 67 68 79 and behavioural counselling and support 4658 for example the open door health lgbtq clinic in rhode island used zoom for patient encounters during the pandemic 48 in other community settings without inhouse physicians such as at the gay city wellness centre in seattle prep consultations were conducted virtually with an offsite physician using a computer in the centre and venepunctures were done by onsite staff members 83 all of the available literature points to the fact that videoconferencing is a highly acceptable satisfactory and feasible approach to promoting service accessibility among geographically dispersed communities especially during the pandemic smartphone applications in eleven projects smartphone applications were used mostly to promote hiv and sexual health through increasing prep awareness 5272 providing hivand stispecific information 47525369 and improving linkage to hiv and sti services 50697278 four projects specified that transgender people were involved in the development stage of these applications 47525357 overall smartphone applications have been reported in the literature as being effective and acceptable in improving hivand stirelated outcomes such applications typically consist of an education component that displays health information and an activity component that includes games and selfrisk assessments some applications such as techstep 57 healthmpowerment 20 47 and trans women messaging social media ecoaching 62 connect 52 also contained interactive functions such as polling and forums that allowed users to connect others such as rumah sela 69 and prepme 72 involved a messaging function for users to connect with a peer worker or health educator to ask hivrelated questions or to arrange prep appointments several incorporated smartphones builtin capacities for instance smarttest 78 used smartphones cameras to help msm and transgender women to interpret athome hiv and syphilis test results users were then able to save and share the test results with doctors another app geopassport 50 assisted msm and transgender women who had recently left prison to navigate hiv and related services the application provided geolocationbased information and cash incentives when a person visited a service messaging nine projects involved sending short messages through a telephone or computer such as sms emails or other instant messengers messaging was another common strategy to promote hiv prevention and care messaging in some cases was unidirectional and in other cases bidirectional and participants were able to customise the types of messages they would receive and select the frequency and timing of messaging for example the interventions itab 80 text me girl 74 techstep 57 and care sms 81 sent predeveloped daily motivational text messages to participants in order to encourage adherence to prep or hiv treatment and to promote emotional health some interventions such as the prepmate study 42 utilised a bidirectional automated response system which required participants to respond to check in messages asking about their prep use study staff then reached out to participants who indicated they needed further assistance or who did not respond to the messages within a set timeframe others such as the wecare 7677 and healthenav 73 projects combined text messaging and oneonone coaching participants in these projects were able to communicate with a designated coach or health educator through text messaging overall the literature indicates that text messaging especially bidirectional messaging is an acceptable effective and personalised way to improve medication adherence and other hivrelated health outcomes 427677 moreover bidirectional messaging also facilitates the collection of realtime data from participants and the provision of timely support 73 ecoaching ecoaching was mentioned in seven projects in these projects coaches who were trained peer workers paraprofessionals or professionals communicated with participants regularly with the exception of one project in which coaches only met with participants in person 50 coaches in all other projects identified and utilised different ict tools eg text messaging 5762737677 video conferencing 58 phone calls 62 emails 88 apps 7677 and social media 767788 to connect with participants in most projects coaches were a rather casual point of contact who delivered personalised support to participants according to individual project aims in the smart project 58 however coaches delivered more structural oneonone counselling sessions to highrisk participants to encourage safer sex behaviors selflearning platforms six different types of selflearning platforms were described in the literature in general these platforms consisted of education components which involved text pictures and videos and interactive components such as games quizzes and forums some interventions such as singularities incorporated elements of roleplaying games and teenage players were able to learn about skills for preventing victimisation and bullying when completing various missions in the game 5960 nevertheless the effects of selflearning platforms alone on positive health change appeared to be small or negligible while studies like singularities demonstrated some improvements in certain shortterm outcomes in the intervention group the study was not powered to find significant effects for most secondary and tertiary outcomes 60 other platforms such as healthmpower successfully engaged with young black cisgender and transgender people through a pointsbased rewards system which allowed participants to exchange points they earned from doing online quizzes and games with real prizes 438485 but there was only a marginally significant effect on change in safesex norms 85 similarly the offline hivclinicbased carespanish did not show any statistically significant effects on the medication adherence and viral loads of spanishspeaking hivpositive cisgender and transgender participants 86 telephone calls three projects described the use of telephone calls phone calls were used as an alternative strategy to connect with participants such as when a transgender patient lacked access to the internet 54 or if they preferred to be contacted by phone over other strategies 62 in some projects telephone warmlines were run to engage with people who had questions with prep 72 in the together 5000 study 63 positive test results of labbased athome hiv testing were delivered to cisgender and transgender participants over the phone by trained staff the phone calls followed a standardised protocol that consisted of mental health assessment and provision of referrals to facilitate linkage to care based on evaluation with cisgender participants the authors found that in general athome hiv testing with phone delivery of results could be an acceptable and feasible way to increase hiv testing access to geographically isolated people compared to email and online portals phone calls were considered the more favourable means for staff to deliver emotional support to users preferring instant live responses 63 social media three projects 62767782 involved the use of inviteonly secret social media platforms to connect transgender people these projects found that social media provided a confidential and safe platform for meaningful exchange of information between peers and in turn promote health by filling social support resource and knowledge gaps for participants especially for those who were younger projects such as wecare combined social media with oneonone coaching and significantly reduced missed medical appointments and increased viral load suppression among cisgender and transgender participants with hiv 77 econsultation platforms two projects 6465 described the use of econsultation platforms to link primary health providers with transgender health specialists using these platforms clinicians who were not familiar with genderaffirming care were able to seek support from a wider network of specialists thereby increasing the access and linkage of transgender people to appropriate care especially for those who lived in rural areas moreover analysing the questions that providers asked could also help researchers in identifying potential gaps in knowledge among primary care providers however some challenges included delayed response from specialists and specialists may provide impractical recommendations because they did not understand the context and difficulties of underresourced settings 64 concerns about ictbased trans healthcare delivery and ways to address them below we present five concerns on delivering ictbased transgender healthcare and ways to address them that we identified from the literature based on critical appraisals of the methodologies and discussions of the individual papers it should be noted that as the majority of the articles we reviewed only consisted of a small number of transgender people the suggestions on addressing concerns summarised below are to some extent general and may apply to other lgbtiq populations content appropriateness and relevance adopting a usercentred approach is an essential component in maintaining the appropriateness and relevance of an ict intervention 434676 many projects consulted community members in the early stages such as by conducting focus groups 4280 or setting up advisory boards 47525357627489 to allow the target population to become an active part of the creative development of the intervention nevertheless most of these projects did not specify the composition of the advisory boards only five projects indicated that the development of the intervention involved direct input from transgender people 4752535774 it has to be noted though that some of these projects only involve two 47 or three 52 transgender persons in the consultation process and it was unclear how their voices were adequately represented in the process safety and confidentiality concerns confidentiality and safety of intervention recipients were concerns documented in the literature 3246486373 for example some participants were concerned that unauthorised third parties could intercept or eavesdrop on technologydelivered healthrelated messages 466386 this was partly because some of this communication was done at an inopportune time of day such as early in the morning or when clients were at work 63 some possible ways to create a virtual environment where people feel safe and comfortable to share their personal issues included setting up privacy protection components and clear instructions for users such as advising them to use headphones 86 for some younger transgender persons they may feel uncomfortable seeing themselves on the computer screen possibly due to dissatisfaction with their own bodies 32 in order to create a safer and more welcoming virtual setting healthcare providers should assess each service recipients comfort with the video function and allow them to disable the camera if needed 32 ongoing software updates and maintenance are also important 73 to keep ict interventions secure safe and relevant limited literacy and access to technology several articles reported challenges in regard to recipients literacy level and access to technology 42464886 some interventions enrolled only people with access to computers smartphones and the internet 68 older people sometimes found it difficult to use technologybased services 464853 poor and unstable internet connections led to glitches that disrupted access to services 467990 appropriate assistance should be provided to help intervention recipients to overcome technical challenges such as assisting disadvantaged people to address financial barriers related to the costs and access to equipment designing interventions using platforms familiar to the target populations was considered as another possible way to facilitate users to adopt a new intervention 76 multiple platforms should also be considered when attempting to reach transgender people of diverse backgrounds and needs 52 physical examinations and suboptimal interpersonal contacts suboptimal interpersonal contacts in virtual settings may hinder health providers ability to perform complete physical examinations and take sample collections 3283 in one project pathology tests were delayed for virtual consultations and physical exams were replaced by visual assessments patient selfexams and selfcollected vital signs 48 getting parental consent for initiating genderaffirming hormones for transgender youth could also be challenging in an online setting 48 therefore some younger transgender people may prefer inperson visits compared to videoconferencing for sexual health care surgical consults and initial gender care visits 32 infrastructural and legal support the broader legal and health infrastructure affects the delivery of ictbased transgender healthcare a challenge described in some studies is the absence of adequate legal frameworks in some countries or localities that are supportive of remote care delivery 7983 crossjurisdictional telehealth could be a problem when clinicians are limited to practicing in specific jurisdictions with their licence 44 moreover studies conducted in the usa highlighted ongoing concerns among providers and clients in regard to the billing of virtual care 487683 in relation to this the usa health insurance portability and accountability act regulations had to be relaxed first so that many providers could adopt diverse technologies to care for their clients during the covid 19 pandemic 90 discussion this scoping review is among the first to synthesise research on ictbased interventions for transgender people our review has identified 39 ictbased projectsprograms 8 types of interventions and 5 common considerations for developing effective interventions for transgender people consistent with the broader literature 78 the range of interventions identified demonstrate the huge potentials of ict to improve healthcare access for transgender people in relation to its flexibility and convenience nevertheless while the body of literature has been expanding rapidly in the past two years transgender people have too often been regarded as a small subsample in ictbased programs and research in some studies transgender people have only represented as low as around 01 of the total sample size 7378 with such a small sample size studies may not be adequately powered to detect the effectiveness of interventions for transgender people many studies did not specificize the involvement of transgender people in the design or evaluation process some studies 4243 even misclassified transgender people as men who have sex with men or transgender as a sexual identity all these findings point to a lack of programs and research that are transgender people specified three major gaps were noted in the literature firstly relatively little is known about the implementation of ictbased trans health interventions outside the context of hiv and sexual health although it has been widely argued that ict can be adopted in other fields such as mental health care genderaffirming care and perioperative care for transgender people 835 only three studies discussed how ictbased genderaffirming care could be provided in realworld clinical settings this finding is consistent with a recent review on mobilebased interventions targeting transgender youth that most interventions have been focusing on hiv and sexual health care 37 the three articles indicated some practical considerations regarding camera use 32 specimen collection and consent process 48 that warrant future studies secondly there is a lack of global evidence and how ictbased transgender healthcare can be best used in resourcelimited settings is yet unanswered while this review included studies from asia and australia most of the included articles were conducted in the usa implementing ictbased interventions in resourcelimited settings have both challenges and possibilities on the one hand there are barriers in relation to technology access peoples computer literacy financial support and regulation of telemedicine 91 poverty human rights situations and sociopolitical contexts also likely affect transgender peoples access to and experience of ictbased interventions 92 on the other hand opportunities exist as healthcare is often provided directly by community peer workers or paraprofessionals in resourcelimited settings a telesupervision model that links frontline workers to remote specialists may help improve access substantially 93 this review included similar interventions in the usa that involved linking primary health providers with transgender health specialists and interventions that supplemented frontline healthcare by community workers with teleconsultations with offsite physicians 83 future research can explore the most effective models of ictbased interventions for transgender people living in different socioeconomic settings thirdly more data are needed to understand the access and experience of subpopulations of transgender people the transgender population is highly heterogeneous and consists of differing racesethnicities ages and other intersectional characteristics as the current literature is dominated by studies from the usa the racialethnic profiles of participants in these studies resemble the demographics of the country which are dominated by white black and hispanic people interventions have often targeted transgender people who are younger english or spanish speaking and who were assigned male at birth future studies could explore how to enhance intervention inclusiveness across diverse ethnic and language groups such as asian pacific islander and indigenous peoples those assigned female at birth and those who are older although the current body of evidence is still far from adequate for us to make comprehensive recommendations on the best practice of ictbased interventions for transgender people the small body of literature has still provided some insights into effective interventions codeveloping interventions with target participants to improve the interventions appropriateness is a case in point nevertheless researchers and health providers must be aware of the risk of tokenism and be transparent in how transgender people are engaged in the consultation development and implementation process in our review only a small number of articles have specified that transgender people were involved directly in the development of the interventions another pertinent point to consider is maintaining humanistic interactions in ictbased interactions for example compared to email and online portals phone contacts were considered the more favourable means for staff to deliver emotional support to users who prefer instant response and a real person to listen 63 in addition to professionally trained practitioners such as doctors and nurses peer workers with lived experience of similar issues add significant value to ictbased interventions especially for interventions that target the community of colour 72 more importantly the success of an intervention depends not only on the intervention itself but also on the broader sociopolitical context such as how transgender people are supported by the legal and health systems systematic adjustments and health advocacy such as establishing a payment policy for telemedicine and allowing longer supplies of medication 48 changing ones gender marker or name on identity documents 8294 and adjusting licensure requirements for crossborder telehealth programs 95 are necessary for ictbased interventions to scale up and better link with other components of the healthcare system limitations similar to most scoping reviews while our use of comprehensive search terms and the practice of citation mining allowed us to capture a wide range of relevant publications it was not possible to identify all literatures in the field it is important to note that the ways and terms by which transgender people identify themselves are rooted in specific sociocultural contexts 96 making it difficult to capture all transgender people our search strategy also limited the review to literatures that are accessed through three databases and the databases we used had their strengths and limitations the search potentially favored articles published from resourceprivileged and englishspeaking countries although a trial search was also conducted in a chineselanguage database which yielded no relevant articles including only peerreviewed articles in this scoping review was another limitation the literature varied in designs sample size and rigour and some of the articles reviewed were research protocols and therefore the degree to which their results could be compared to each other and the transferability of their conclusions was unclear despite these shortcomings we believe that our efforts help summarise and identify knowledge gaps on the types of work that have been done on this topic thereby informing further work in this area conclusions while there is a rapidly growing literature on the use of information and communication technology to deliver healthcare to sexual minorities transgender people are often still regarded as a subsample in most ictbased programs and research future interventions in addition to hiv and sexual health should also focus on other unique health needsissues that transgender people experience such as mental health and gender affirming care it can also be of great importance to explore how ict can be used to improve the health of transgender people from diverse sociocultural backgrounds crucially the success of an ictbased intervention depends not only on the intervention itself but also on how transgender people are supported in the broader sociopolitical context health researchers have a responsibility to adopt a more inclusive approach in the design and delivery of interventions that are safe accessible and effective while continuing to advocate for the rights and health of transgender people from different policy perspectives all data analysied have been listed in the main text of the scoping review

in the recent past there has been a strong interest in the use of information and communication technology ict to deliver healthcare to hardtoreach populations this scoping review aims to explore the types of ictbased health interventions for transgender people and the concerns on using these interventions and ways to address these concerns guided by the scoping review frameworks offered by arksey omalley and the prismascr checklist literature search was conducted in may 2021 and january 2022 in three databases pubmed cinahl and scopus the two searches yielded a total of 889 nonduplicated articles with 47 of them meeting the inclusion criteria the 47 articles described 39 unique health projectsprograms covering 8 types of ictbased interventions videoconferencing smartphone applications messaging ecoaching selflearning platforms telephone social media and econsultation platforms over 80 of the health projects identified were conducted in north america and 62 focused on hivsexual health the findings of this review suggest that transgender people had often been regarded as a small subsample in ictbased health projects that target other population groups such as men who have sex with men or sexual minority many projects did not indicate whether transgender people were included in the development or evaluation of the project relatively little is known about the implementation of ictbased trans health interventions outside the context of hivsexual health in resource limiting settings and among transgender people of asian indigenous or other nonwhiteblackhispanic backgrounds while the range of interventions identified demonstrate the huge potentials of ict to improve healthcare access for transgender people the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ictbased interventions for transgender people future ictbased interventions need to be more inclusive and plos global public health

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introduction an increasing percentage of older adults wish to be cared for in their homes resulting in a rise in the need for home care services for this group home health aides provide the bulk of the direct care provided in the home they are members of one of the fastest growing fields ranking third on the list of fastest growing occupations with an expected growth of 48 between 2012 and 2020 though this sector of long term care is quickly expanding there remain challenges for this critical workforce turnover rates among hhas are particularly high falling between 35 and 65 per year in addition job dissatisfaction is regularly reported dissatisfaction on the job is an important employment outcome because it is correlated with high rates of burnout low selfesteem depression and anxiety finding ways to improve employee retention and job satisfaction is a significant priority in the field hhas work very closely with their older patients providing care that is intimate and personal the nature of this work often results in the development of close relationships with patients for some hhas this opportunity to develop interpersonal relationships is one of the major reasons they came into the field and continue to remain on the job research evidence has shown that hhas who develop close ties to the patients and their families experience significant grief when a patient dies yet the grief reaction of direct care staff has been recognized as one form of disenfranchised grief hhas may also have a role in comforting the family in the initial aftermath of the patients death mcclement and colleagues reported from their study on hha perspectives on care of dying patients that hhas considered conveying their sympathy to family members after the death and appreciating the familys need to reminisce as important tasks in providing high quality care however home care agencies often do not have adequate protocols or structures in place to support their staff members in the context of patient death for example home care agencies do not always notify their staff of a patients death and some have policies in place to prevent any followup contact with a deceased patients family little is known about how these types of agency factors affect hhas work experience the study compares a home care agency with a restrictive contact policy with one that has no such policy our first aim was to test the hypothesis that hhas employed by agencies with restrictive policies would be more likely to consider other career options and more likely to be less satisfied with their job our second and third aims were explorative we examined whether hhas differed with regard to other key outcomes of the study including relationship to patient and family caregiving benefits experienced at work and their grief symptoms and grief processing after the patients death finally we explored responses from openended questions throughout the interview for comments pertaining to policyinstructions to illustrate hha perceptions and reactions methods recruitment and eligibility the present analysis is part of a larger mixedmethods study that looked at bereavement in direct care workers we recruited actively employed hhas from the community service division of an elder care system in greater new york and two other agencies subcontracted by this longterm care organization hhas had to have experienced the death of a patient for whom they were the permanent hha within approximately two months to be eligible the participating agencies administrative staff informed us when patient deaths occurred and asked the primary hha of the deceased patient if it was permissible for study personnel to contact them if the hha agreed study staff followed up with a phone call to explain the study and schedule an interview since english language proficiency was not a job requirement for hhas and the pool of potential participants included individuals whose primary language was spanish hhas could choose to complete the interview in spanish of a total of 122 hhas we attempted to reach 38 could not be reached within two months of the patients death 80 out of the 84 we were able to reach agreed to participate and the other four refused thus the overall response rate was 95 the participating hhas were representative of the larger pool of hhas serving the organizations patients with regard to age gender and tenure however when compared by raceethnicity we found a difference in the proportion of black and hispanic hhas our study sample was 67 black and 29 hispanic whereas the larger pool of hhas was 33 black and 64 hispanic we did not purposefully choose agencies based on their policies regarding follow up contact or inquiry about patient death however over the course of data collection hha accounts of their experience after patient death alerted us to this issue we subsequently reviewed the participating organizations relevant policies and found that we had included one agency with a concrete policy not to have any followup contact in place one agency with no such policy in place and one agency that would not specify a relevant policy since we had only two participants from the latter agency we decided to focus on comparing the two agencies with clear positions re followup contactinquiry after patient death thus the final sample for the present paper was n78 data collection and measures the oneonone interviews were conducted inperson by trained interviewers with a bachelors or masters degree interviews were conducted at a place and time that was convenient to the participant and lasted an average of 80 minutes prior to all interviews written informed consent was obtained and participants received 30 for their time interviews were never conducted during the hhas work hours sociodemographic and background characteristics assessed included gender age education ethnicity race and marital status additionally noted were numbers of years worked as hha number of months having cared for the deceased patient and the time between the interview and the patients death hhas possible intention to leave the job was assessed with a singleitem taking everything into consideration how likely is it you will try to pursue a different line of work within the next year very likely not likely at all job satisfaction was assessed with a shortversion of the job description index a popular and widely used measure of job satisfaction this measure consists of six subscales work pay promotion supervision coworkers and general satisfaction standard scoring for the jdi was used cronbach alpha for the subscales in the present study ranged from 70 87 relationship with patient was assessed on a scale measuring rewarding aspects in the relationship between caregiver and care recipient hhas were asked how often they felt happy with their relationship with the patient the patient made them feel good about themselves they felt very emotionally close to the patient they felt bored with the patient scores indicated the extent to which the relationship is perceived as rewarding cronbach alpha in the present study was 76 positive aspects of caregiving were assessed with an 11item scale that has demonstrated excellent psychometric properties and has emerged as a strong predictor of bereavement outcomes in previous studies of family caregiving and bereavement items reflect caregiving benefits such as made me feel useful or enabled me to appreciate life more higher scores indicated greater caregiving benefit cronbach alpha in the present study was 78 grief symptoms were assessed with the 13item version of the texas revised inventory of grief a validated scale to assess current symptoms associated with separation distress responses ranged from completely false to completely true this scale has been successfully used in large national bereavement studies and thus is suitable for comparison with the family bereavement literature cronbach alpha in the present study was 76 grief processing was assessed with a scale developed and validated by bonanno and colleagues this scale measures 5 thoughts and behaviors all items are rated on a 5point scale for frequency of occurrence cronbach alpha in the present study was 88 openended questions exploring hhas experience after patient death to which hhas provided responses related to the contact restrictive policy included inquiry about how they responded to hearing about the death how they felt about how they were notified about the death how they felt about how their reassignment to a new case was handled what kinds of interactions they had with the patients family after the death what if any training regarding death and dying they got from their employer what kind of rituals took place after the death and if they participated and what kind of acknowledgement of patient death they would like the agency to have in place a coding system for the openended data was developed with an analytical themeidentification approach often used in qualitative analysis kappa coefficients consistently ranged from 75 to 1 demonstrating adequate interrater agreement findings descriptives of sample characteristics and major study variables are displayed in table 1 participating hhas were mostly women reflecting the larger population of hhas about one third identified as hispanic and two thirds of the sample identified as black most hhas were high school graduates or had at least some college almost one third indicated being married or living as married another third being divorced or separated and a little more than a third reported having never been married about half of hhas reported never having experienced a patient death before on average the hhas had been working in the profession for 6 to 7 years and cared for their deceased patient for 18 months findings from group comparisons are depicted in table 2 addressing aim 1 hhas from the agency with a contactrestrictive policy were significantly more likely to express an intention to consider other job options within the next year as expected they were also likely to report significantly lower job satisfaction with respect to one of the six subscales supervision received in the work place four other subscales also indicated lower satisfaction scores for this group however these differences were not substantial enough to reach significance the only subscale with almost identical means was satisfaction with pay which was visibly low in both groups to be able to put the employment outcome findings in the larger context of the hhas experience we additionally conducted group comparisons for key relationship caregiving and grief outcomes while there were no group differences with regard to perceived hhapatient relationship quality caregiving benefits experienced in the workplace or grief symptoms after patient death hhas from the agency with a contactrestrictive policy reported significantly less grief processing activity thus findings suggest that hhas from the two agencies were similar with respect to the closeness of their relationship to their patient and the sense of meaning or purpose derived from their caring role but despite these similarities the hhas from the agency with a contactrestrictive policy may have had fewer options for exchange and processing of this experience finally to give voice to the experiences of hhas from the agency with contact restrictive policy we carefully examined all responses to openended questions throughout the interview for this group narrative accounts indicated that hhas had developed a close relationship with patients and family and they perceived their agencys restrictive policy regarding followup contact after patient death as problematic when talking about this they also sought reassurance from us that the interview is confidential specifically some reported that they would have liked to have had such contact to offer condolences or attend a funeral but abided by the agency policy whereas others decided to go against the policy and make contact with the family after patients death discussion overall study findings suggest that hhas from the agency without a contactrestrictive policy had a more positive experience at work and more opportunity to process the patients death this is a tentative conclusion as we were not able to directly test if variance in employment outcomes is related to policy differences it is however notable that the groups can be characterized by differences on these outcomes whereas similar differences do not emerge for other key variables moreover narrative responses throughout the interviews in response to various interview questions reflected hhas perceptions that policy plays a role in their experience and that the contact restriction is perceived as a negative factor in their work life that this theme was so present in hhas accounts despite the fact that we had not specifically asked about it is also remarkable homecare agencies with similar restrictive policies around patient death may want to consider reviewing such policies and their possible impact on employees another important question in this context not addressed in the present study may be how family members experience the situation when an aide who has cared for their loved one does not seek any contact after the death a closer look at policies and protocols related to patient death and dying in home care may benefit hhas and their agencies by addressing a source of dissatisfaction and discomfort among employees and at the same time nurture an environment where patients and families feel cared for in a compassionate way it is also important to note that working in a restrictivepolicy environment may impact the hhas relationship with their supervisor as well as their overall perception of the agency in which they work previous research has found that the quality of the supervisory relationship as assessed by the direct care worker can be an important predictor of overall job satisfaction and retention additionally feeling supported by the agency and facility where they work has also been found to influence direct care worker job satisfaction and when positive to lower turnover if hhas are experiencing a negative reaction due to the way that their supervisor and agency are handling the death of their patient it has the potential to threaten the quality of these critical relationships and in turn impact hhas satisfaction on the job and even their decision to remain in their position this article presents results on a topic that has rarely been examined and thus deserves greater attention and study with the instability present in the home care workforce particularly related to turnover gaining a better understanding of agency policies that may be impacting hha satisfaction is important for improving the working conditions of these workers though this particular facet of the described study was exploratory it brings to light an issue that requires additional research further exploration into agency policies as they relate to patient death family contact and other interactions during critical transition times are needed to better understand the effect on the direct care workforce home healthc now author manuscript available in pmc 2017 april 01 suggested callouts turnover rates among hhas are particularly high falling between 35 and 65 per year research evidence has shown that hhas who develop close ties to the patients and their families experience significant grief when a patient dies hhas from the agency with a contactrestrictive policy were significantly more likely to express an intention to consider other job options within the next year as expected narrative accounts indicated that hhas had developed a close relationship with patients and family and they perceived their agencys restrictive policy regarding followup contact after patient death as problematic

home health aides are members of a rapidly growing occupation and often develop close ties to patients and their family and can experience significant grief when a patient dies yet agencies often provide little support or structure to help staff cope during this time for instance home care agencies do not always notify their staff of client death and some have policies in place to prevent any followup contact with a deceased clients family little is known about how these agency factors affect hhas work experience this mixedmethod study explored the experiences of 78 hhas working either at an agency with a restrictive policy regarding contact with a clients family after client death or an agency without such a policy in place data was collected through semistructured inperson interviews employment outcomes included various aspects of job satisfaction and intention to change jobs hhas responses to client death were assessed with measures of grief and grief processing and with openended questions exploring their experiences in this context findings indicated that hhas from the restrictive agency were significantly more likely to be considering other job options they also reported significantly lower satisfaction with received supervision and significantly less grief processing activity findings suggest that hhas from the agency without a contact restrictive policy had a more positive experience at work and more opportunity to process the clients death

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introduction defines sustainable development as a process of growth which meets the needs of the present as perceived by all concerned and maintained over a long period after project inputs have ceased without compromising the ability of current and future generations to meet their needs talking about community empowerment cannot be separated from the efforts for sustaining the development says that community members become the main business party in a community empowerment project so the sustainability thoughts can also be traced from business perspective such businesses desired to change the world through social environmental and economic values which are called together as the triple bottom line understanding sustainable development and its goals is the first step to learning what we can do to make it happen community projects are intended to transform the economic wellbeing of the locals leading to poverty reduction the sustainability of these projects is a great concern since most of the projects are politically instigated it is for this reason that project implementers face continuous internal and external pressures from project donors the taxpayers and the entire community at large a project is believed to be sustainable if it continues to provide some level of benefits after the donor terminates major financial managerial and technical support various studies have been conducted to measure sustainability as research in this area expands approaches to measuring project sustainability are gradually becoming more sophisticated which has generated a more detailed understanding of the antecedents contributors and processes central to an application of sustainability principles politically instigated projects face challenges of sustainability due to the politicians occupancy period in the county a big percentage of these projects end up failing and others pick at a slow rate how then can we ensure these projects continue long after they are gone what factors contribute to sustainability of projects the study assessed factors that contribute to sustainability of county projects the case study for this research was the oparanya care system a program dubbed afya ya mama na mtoto in kakamega county that was developed with an aim of reducing the high infant and maternal mortality rate and other cases associated to poverty that mostly cause death to women and children during and after child delivery the project software is under continual improvement to fit user and customer needs this study aimed at assessing the mechanisms of sustainability of the project with the following specific objectives to evaluate the economic aspect as an instrumental factor to sustainability of projects to investigate the social effect as an instrumental factor to sustainability of projects and to assess the influence of resources as an instrumental factor to sustainability of projects the study contributes greatly to facilitators of community based projects bringing out issues brought forward by different stakeholders and lastly will give recommendations on how the community based development projects can be made sustainable after phasing out donors literature review theoretical frame work in precise perspective sustainability means the ability to sustain some entity outcome or process over time theories of sustainability attempt to highlight and incorporate social responses to environment and cultural problems these theories of sustainability raises unambiguously basic question can human activity successfully maintain itself and its goals without exhausting the resources on which it depends according to sustainability involves two types of issues one sustainability insists on the importance of perpetuity of not endangering the ability of the earth or of humankind to go ahead with existing secondly it embodies a concern as to the intergenerational route to be followed by our societies and raises questions like will the future generations be able to have the same level of consumption are we going to transfer the earth in a worst state is growth in whichever of its forms sustainable at all according to it took quite a number of years of intensive work to reach a global consensus on the elements of sustainable development it was finally achieved in 1995 at the world summit on social development the explanation brought together what is popularly known as the three es environment economy and equity comes with a framework containing seven major elements of sustainability leadership competence effective collaboration understanding the community demonstrating program results strategic funding staff involvement and integration and program responsivity they say that these elements are primarily within the control of program leaders and stakeholders but a program could have limited life because of factors outside its control such as state or local budget shortfalls or the emergence of other programs and organizations debates of sustainability aspire to sort out different opinions with this regard the evaluation policies and components of sustainable development should be researched empirical review sustainable neighborhoods need to be a central concern of community development says necessary community empowerment and a sense of community is an idea of sustainable development it is one of the major points of the millennium development strategy notes that though communitybased programs are significant in the service delivery system in many communities most of them lack awareness of sustainability he says that a sustained program preserves a focus consonant with its original goals and objectives with the individuals families and communities it was originally planned to serve majority of studies done on community development have evidently revealed the deficiency of interest in government initiatives to spearhead development according to the principle of community development is popular participation he goes on to say that popular participation deals with broad issues of social development and the creation of opportunities for the involvement of people in political economic and social life of the nation thus in this way it prepares a way for community participation a concept which connotes the direct involvement of ordinary people in local affairs such as building of roads schools or election of local and civic leaders economic pillar community development is an organized intervention that gives communities better control over the conditions that affect their lives it provides ways of facilitating and providing sustainable livelihoods in communities and in addition ensures a countrys economic growth the economic impacts of a project are effects on the level of economic activity in a given area in these they study looks at three two factors tax benefits and reinvestments together their effects can be thought of as the ripple effect of the initial change in economic activity for instance across all economic sectors per each new job created directly or per each dollar increase in earnings or business sales according to the link between the taxes generated by the project and the social benefits arising from the use of those taxes he says that the taxes are spent in diverse areas such as health education housing etc the social benefit arises from the tax spend in each area the tax spend in each area is then multiplied by the pertinent factor to obtain the social benefit in when people are capacitated they are able to regenerate money from that little income for instance just a single purchase of goods and services from local suppliers supports the employment of staff at those firms and empowers those firms to purchase additional inputs from their suppliers situated further down the supply chain additionally the companys employees earn salaries and wages some of which they will spend on local goods and services in a wide variety of industries that spending supports workers in those firms who also will spend portions of their incomes locally and so on with this logic a typical economic impact analysis approximates the total impact of a change in economic activity as the sum of effects on three different levels social pillar the communal support and acceptability community commitment societal cohesion is very important for sustainable development according to social conditions and cultural beliefs contribute to a communitys sense of engagement in the health of women and children changes to attitudes and behaviors are challenging to implement incentivize sustain and measure though social equity is often hard to quantify measures which evaluate income employment literacy access to housing and health care among many others are both available and useful a myriad of different meanings are attached to the term social there are also difficulties regarding the identification of purely social issues as considerable overlaps exist across sds three pillars this overlap is particularly pronounced with respect to the economic and social pillars with many issues most notably employment and unemployment deemed relevant to both dimensions despite these circumstances the literature points to certain policy concerns that have been identified as social within the overall sd framework these have been variously described as social categories social themes social dimensions social indicators and the social realm many projects play a significant role in employment creation and income generation in the view of there is an extensive consensus among many actors who are concerned with sustainable development these includes the united nations the international labor organization and the international cooperative alliance they all agree that the cooperative enterprise is the type of organization that is most suited to addressing all dimensions of reducing poverty and exclusion as cooperatives help reduce poverty it is important they identify economic opportunities for their members empower the disadvantaged to defend their interests provide security to the poor by allowing them to convert individual risks into collective risks and mediate member access to assets that they utilize to earn a living globally more than 100 million jobs exist in cooperatives as cited by the ica together with small and mediumsized enterprises cooperatives are the most significant sources of new employment while global data on cooperatives contributions to creating employment needs improvement available country evidence is quite compelling according to the british columbia round table on the environment and economy socially sustainable communities are able to achieve and maintain personal health physical mental and physiological feed themselves adequately provide adequate and appropriate shelter for themselves have opportunities for gainful and meaningful employment improve their knowledge and understanding of the world around them find opportunities to express creativity and enjoy recreation in ways that satisfy spiritual and psychological needs express a sense of identity through heritage art and culture enjoy a sense of belonging be assured of mutual social support from their community enjoy freedom from discrimination and for those who are physically challenged move about a barrierfree community enjoy freedom from fear and security of person participate actively in civic affairs defines culture as the whole complex of distinctive spiritual material intellectual and emotional features that characterize a community society or social group it includes not only arts and literature but also modes of life the fundamental rights of the human being value systems traditions and beliefs they also emphasize cultural resources to include all of the tangible and intangible heritage and living cultural elements of a community in the view of cultural resources are renewable this is extremely valued in the current economic and environmental crisis a renewal of the sustainable concept is of a special kind this is welcome to ensure that the sustainability concept does not lose momentum capability development and skills training are determinants of successful developments for a project to realize its objectives the guidelines of the project cycle must be vigorously implemented according to cultural diversity is evolving within and across communities ideally cultural diversity changes over time and is shaped by human mobility and aspirations few policies reviewed acknowledge that evolving nature of cultural diversity requires preservation of cultural traditions to ensure sustainability resource pillar according to the resource usage indicators attempt to capture the key value of the resources used during the lifetime of the project in view sustainable community development requires local economic development to enhance community life by using the local talents and resources of the local community according to resources are a key aspect in managing any business they also offer a wide range of opportunities in a balanced sustainable approach people may be the most significant asset a company has the organizationcompany must then know how they are deployed for this affects them as individuals and also the operating costs also adds travelling is tiring timewasting and costly but business travel does not seem to abate technology allows greater flexibility for home working but commuter traffic remains congested balanced approach could reduce travel and improve personal performance in this case efficient equipment is a major consideration development in a community as notes has been understood as a collective process of cultural advancement it involves creativity interpreted in the broadest sense this contributes to changes in peoples lives and long term developmental benefits for a community it is in relation to this that adds that cultural development in a community incorporates a huge range of activities that give communities the opportunity to tell their stories build their creative skills and be active participants in the development of their culture consumable resources are not constrained on a periodic basis but rather have a limited consumption availability for the entire project sustainable development requires assimilating communities to ensure acceptance it also requires that local economic development supports community life using the local talents and resources of the local community in the view of capacity building is an approach to development not a set of predetermined activities there is no single way to build capacity in regards to sustainability capacity building has been identified in much sustainable development policy as one of the key strategies for increasing the potential towards sustainable development according to community participation technology selection site selection demand receptiveness construction quality population and training are some of the preimplementation factors he also cites the postimplementation factors as the technical support community satisfaction institutional and financial management training and willingness to sustain community projects all these contribute to an efficient sustainable development the significance of infrastructure to a community is comparable to the foundation the human skeleton plays in the general structuring functioning and health of the body economically says infrastructure is costly involves significant upfront capital for benefits that are spread over time and is afflicted with complications with cost recovery the improvement of community infrastructure is a critical means of increasing physical links between poor rural communities and the outside world the corporate evaluation attributed the sustainability problems with infrastructure to a number of institutional and technical factors it found that donors often implement infrastructure projects with unjustifiable rush forgoing rigorous institutional analyses and in some cases prematurely accepting government assurances that project interventions will be adequately maintained once in place the evaluation concluded that in many infrastructure projects officials are motivated to achieve physical and financial targets and place little significance on facilitating a sense of community ownership finally it observed a frequent mismatch between the technical standards of infrastructure projects and the human social and financial capital available at the community level to operate them beyond project completion sustainability of projects sustainability say is the likelihood that a project shall continue long after the external support is withdrawn subsequently while thinking of project sustainability three things must be born in mind the community project results and external assistance a project is sustainable if the beneficiaries are capable on their own without the assistance of outside development partners to continue producing results for their benefit for as long as their problem still exists globally billions of shillings have been spent in communities to improve the living conditions of the people the concept of sustainability can be seen within time and changing social economic and political contexts sustainability is reflected in the capacity of the community to handle change and adapt to new situations says a project that is seen as worth sustaining today may not be so in future says sustainability is affected by a number of issues including those internal to communities and their dynamics those influenced by the project design and factors external to the particular context add that despite vast amounts of money spent on implementation of projects in kenya poor sustainability is depriving them from the returns anticipated from these investments a number of factors are attributed for the poor project sustainability some factors are simple and others are quite complex some are within the control of the project management while others come as external threats in an another view says sustainability is considered to be a multifaceted continuous and cyclical process of organizational change that has four major objectives continuing project activities within the funded organization sustaining benefits for the intended stakeholders maintaining the capacity of a collaborative structure and maintaining attention to the issues addressed by the program the definition of sustainability emphasizes the aspect of future orientation as a fundamental component this care for the future implies among other things economic social environmental and resource factors when talking about the economic factor says it implies that adequate local resources and capacity exist to carry on with the project in the absence of outside resources says adequate finance is a key resource in a project without which it cannot operate and so the resource should be given the attention it deserves if projects have to survive financial planning he says involves setting objectives assessing assets and resources approximating future financial needs and making plan to achieve monetary goals he opines that one systematic approach for achieving effective management of project is through financial planning budgeting and that sustainability of any project lies in effective financial management right from the implementation stage to post implementation phase the resource factor for sustainability of projects is equally very important for project sustainability say occasionally a project ends and resources suddenly decline causing further imbalance in the view of culture is gradually emerging out of the realm of social sustainability and being recognized as having a separate distinct and integral role in sustainable development within the community development field culture is broadly defined as the whole complex of distinctive spiritual material intellectual and emotional features that characterize a society or social group according to different studies the dimensions of sustainability which are effective in promoting duration of a project are yet to be fully understood the fundamental requirement to achieve sustainability is a dynamic balance in different factors modest improvements in the economic status of those who are claimed to be the beneficiaries of different community projects and programs either government or privately sponsored is yet to be quantified in addition the indication that beneficiaries have managed to break out of selfreproducing spirals of impoverishment is minimal even people helped by successful projects still remain poor it is in this context plus having found minimal literature related to the topic of research in the selected area of study there is a gap and thereby seek to explore the factors that affect sustainability of county projects in kenya research methodology the research design used for the study was a crosssectional evaluation survey that evaluates a specific case study the target population for this study included the all the 72 project officers who represented the sponsors and implementers in addition the project beneficiaries were 30000 mothers the sampling technique used was stratified random sampling the stratified random sampling design involved the dividing of the population into mutually exclusive or homogenous groups and then drawing random samples from each group sampling was used to secure a representative group which enabled the researcher to gain information about a population according to since the target population was 10000 the sample size was adjusted accordingly as shown below 2 2 z p q n d  n was therefore equal to 384 hence all the individuals who were affected by the oparanya mother care project and its implications were represented by the selected sample the data collection tool that was used for the study was the questionnaire it blended open ended a closed ended questions the data was collected by a research assistant questionnaires were dropped and picked for those who could not read and write questions were orally administered and interpreted for the respondents to understand the data enumerator then filled questionnaire the data was collected over a period of one month to meet the requirements of crosssectional survey validity was determined by the use of face validity and content validity face validity tests whether the questions appeared to be measuring the intended constructs the content validity tested whether all the important aspects of the constructs were measured this was done by first testing the instruments on 10 of the target population and reviewing the findings the responses were tested using the cronbach alpha which is a measure of internal consistency it is considered to be a measure of scale reliability a pilot study was conducted where the content validity and reliability of the questionnaires were tested the validity was enhanced through discussion of the questionnaire contents with three randomly selected project officers and three project beneficiaries the reliability was tested through statistical package for social sciences and cronbach alpha correlation coefficient was used to satisfy the reliability tests the pilot study helped in correcting the questionnaire it was discovered that the age brackets did not capture all respondents therefore the study included an age bracket of 10 17 years it was noted that even young girls as old as 15 years had children secondly the questionnaire included questions on environmental effect as one of the pillars of sustainability however it was noted that the oparanya care program had little or no effect on the environment after the corrections and additions were made to the questionnaire the cronbach alpha reliability tests of each of the variables was as follows 09 for economic pillar 0850 for social pillar resource pillar 0802 and finally sustainability at 0782 for each of the independent variables α was greater than 07 this conforms to that a minimum of 07 value for α is acceptable for a research instrument hence the acceptance of the research instrument as valid for this study the data processing operations that were carried out included data editing cleaning and classification the obtained data was analyzed using both qualitative and quantitative techniques descriptive statistics was used for the analysis of the collected data and this included parameters such as measures of central tendencies and the measure of dispersion inferential data analysis techniques such as regression and correlation analysis were also used to analyze the collected data data analysis and presentation of findings were done using statistical softwares including spss and microsoft excel these softwares aided in the generation of suitable graphs charts and tables which were used in presentation of the research findings regression analysis was used to test the relative relationship between the independent and dependent variables the data collected from the field was captured using statistical package for social sciences version 21 and microsoft excel the final report was prepared based on the findings research findings and discussion the analysis is of two types namely descriptive statistics and inferential statistics descriptive analysis was used to describe the data and mainly involved frequency distributions calculation of mean and standard deviation on the other hand inferential analysis involved correlation and regression analysis to find the relationship various variables a total of 384 questionnaires were dispatched 72 of these targeted project officers whereas 312 questionnaires were sent out to the project beneficiaries a total of 323 questionnaires were returned according to dixon a response rate of 50 was adequate while a response rate greater than 70 was very good this agreed with that a 50 response rate is adequate 60 good and above 70 very good this therefore implied the response rate of 841 was very good 71 of the respondents were between the age of 1017 this was from the county documents further a cross tabulation was done to confirm the number of beneficiaries in this category the beneficiaries were 257 spread across all age brackets it was noted that there were 23 beneficiaries in the age bracket of 1017 meaning there were some really young mothers involved in the project role of economic pillar in sustainability of projects economic sustainability is used to define strategies that promote the utilization of socioeconomic resources to their best advantage in this study economic benefits of projects such as employment increase in investments and overall project benefit were tested one of the highest rated response was increase in employment at 398 translating to 796 an increase was also noted in government revenue at 722 the two could be associated with the community having more income leading to increase in purchasing power this is in corroboration with who says that the effects can be thought of as the ripple effect an initial change in economic activity for instance new job created directly increase in earnings moreover when people are capacitated they are able to regenerate money from that little income 783 agreed that the program has increased investment opportunities in the area these findings corroborate with the who opines once people are capacitated they are able to regenerate money from that little income additionally the companys employees earn salaries and wages some of which they will spend on local goods and services in a wide variety of industries that spending supports workers in those firms who also spends portions of their incomes locally and so on with this logic a typical economic impact analysis approximates the total impact of a change in economic activity as the sum of effects on three different levels the mothers are not restricted on how to spend the money but they are advised to buy milk and food for their children and themselves however some commented they have reinvested the money and opened up small business which in turn gave them some source of continuous income a qualitative question on the respondents opinion on the source of funds for ensuring project continuity was put forward the table 1 below explains the results 39 of the respondents felt that the governmentsirikali should engage in the project through funding the county to ensure its continuity 75 of those who thought the government should support the initiative were the project beneficiaries this could be attributed to the fact that governmentserikali should support every community project however 483 of the project sponsors felt that the corporate world could come in handy through corporate social responsibility role of economic pillar in sustainability of projects the contribution of the project in social perspective was evaluated the reduction of maternal and newborn mortality and morbidity continues to be a great challenge in most developing countries kenya included it is specifically for this reason the project was conceptualized all the project sponsors thought the program had reduced the maternal mortality rate more than half of the project implementers that is 595 also agreed with the statement however only 402 of the beneficiaries felt that the program had decreased mortality rate the expectation of the project beneficiaries could have been so high it is possible the pregnant women together with their families anticipated for a healthy pregnancy a safe delivery and a normal healthy babies however some may have lost their babies at child birth others may have miscarried according to the program reported that the national average of safety deliveries stood at 56 the community wellbeing and their safety was also tested in this study because apart from ensuring motherchild safety during delivery the project aimed to ensure the two will be taken care off even after delivery 693 of all the respondents were in agreement with the statement the oparanya care cash transfer programme aims at encouraging women to attend antenatal clinics and deliver safely in hospitals during the clinics the mothers are advised on the type of foods to wean the children about balanced diets the children are vaccinated in the process it was noted that majority of the children before the programme were malnourished and sickly this agrees with the british columbia round table on the environment and economy socially sustainable communities are able to achieve and maintain personal health feed themselves adequately 1994 role of resource pillar in sustainability of projects according to the literature sustainable community development requires local economic development to enhance community life by using the local talents and resources of the local community this research sought to understand if the oparanya project had any effect on communities way of like 714 agreed that the project delivered tangible resources says that the project targeted two health facilities in each sub county which was used to offer the required services however the project has not realized its set goals in terms of resources nevertheless the county still has plans to increase the number of facilities in each of the 12 subcounties from two to four to save mothers in remote villages from walking long distances to reach health facilities for services further a cross tabulation to establish more on the proper community empowerment was done to find out how different category of the respondents agreed to this statement the respondents from all the categories agreed at 876 that lack of proper community empowerment can affect project sustainability these findings relate to a speech delivered by the first lady of kakamega county that small things in life like encouraging a daughter to find her dreams and helping her achieve them appreciating the efforts and helping a woman at home equal treatment of children either boy or girl making them believe in themselves and increase their selfesteem and selfconfidence by letting them make important decisions that are relevant in their lives it is necessary to make a woman feel safe inclusive of other considerate gestures shown to women at the basic unit called family this will impact the society positively and tremendously more than any lofty womens day celebrations will she adds that whenever the relevant ward administrators and mcas are effectively sensitized it becomes easier to spread the information to higher levels schools institutes and all the academic centers get better placed to acquire the sensitization consequently in every health facility located in all the subcounties the health workers should always endeavor to talk about reproductive health matters the distribution of reproductive health issues differs extensively in the subcounties and therefore based on the statistics then much has to be done stakeholder influence on projects the study found out that stakeholders play a vital role in cbps from the findings it was seen that majority of the respondents felt that sponsors influence at 715 government at 634 and community at 742 the community represented a higher percentage this could be accredited to the fact that they are the ones receiving aid and that its their actions that will determine project success or failure in addition the sponsors provide the funds so they have a great stake in the project says adequate finance is a key resource in a project without which it cannot operate and so the resource should be given the attention it deserves if projects have to survive the government too plays a key role because it provides the platform for the projects to run regression model between sustainability of projects and role of economic social and resource pillars the fitted regression model is of the form where is the dependentoutcome variable that is the sustainability of projects is the role of the economic pillar is the role of the social pillar is the role of the resource pillar is the intercept the value of the dependent variable when all independent variables are set to 0 where y is the dependent variable x 1 is economic pillar x 2 is social pillar and x 3 is resource pillar according to the regression equation taking all factors constant at zero sustainability will be 0 out of 5 the data findings also show that a unit increase in economic pillar will lead to a 0235 increase in sustainability a unit increase in social pillar will lead to a 0287 increase in sustainability a unit increase in resource pillar will lead to a 0033 increase in sustainability conclusions based on the findings it was concluded that economic social and resource pillars all affect the sustainability of the project adherence to sustainability indicators integration of economic social aspects integration of short term and long term aspects can enhance sustainability of the project more the economic pillar and the social pillar had a higher impact they both deal with social needs therefore it is necessary to engage both citizens and community partners to plan and act in response to these needs which will lead to the overall wellbeing of the whole community realizing project sustainability is not a short term assignment but a continuous process because community based projects are sophisticated therefore requiring composed management skills empowerment in terms of information skills and resources is a fundamental aspect for sustainability of these projects institutions managing project implementation from the community to the national or international levels need to be well facilitated economically and socially the cbp has empowered the community through health education and monetary terms this per the findings has consequently changed peoples lives and has added long term developmental benefits to the community the aim of the project was to help the mother and the child but from the findings the entire community has benefited from the same however more stakeholder involvement is necessary to ensure that the project can run even after the funding is over generally the studied variables are instrumental to the sustainability of projects and if well observed they contribute highly to the mutual benefit of all the stakeholders involved in the project implementation recommendations economic sustainability involves making sure the project is successful but also that its operations do not create social or environmental issues that would harm the longterm attainment of the set goals of the project secondly since the transactions are carried out through mpesa the county government could come with an agreement with the mobile phone companysafaricom that as part of corporate social responsibility it could donate a certain percentage per transaction towards the project resources are a key aspect in managing any project they offer a wide range of opportunities in a balanced sustainable approach people are the most significant asset in any project the organizationcompany must then know how they are deployed for this affects them as individuals and also the operating costs secondly consumable resources are not constrained on a periodic basis but rather have a limited consumption availability for the entire project therefore efficient utilization is crucial the social aspect of sustainability focuses on balancing the needs of the individual with the needs of the group the social pillar helps social agencies and residents to raise awareness about social needs and to engage both citizens and community partners to plan and act in response to these needs the end result improves the wellbeing of the whole community though social equity is often hard to quantify measures which evaluate income employment literacy access to housing and health care among many others it is both available and useful with this the study stresses the importance of balancing the needs of the individual with the needs of the project in full access to effective health care housing food and education services which are essential prerequisites for full participation in cultural social and economic activities areas for further research this study has appraised the oparanya care project when it is still running therefore a further study can be done after the oparanya mother care project has been completely executed to evaluate whether the project is still sustainable the study variables only accounted for 42 of the factors instrumental to the sustainability of the project a more detailed study can be conducted to establish the other factors that contribute towards sustainable projects

a project is considered to be sustained if it continues to deliver a high level of benefits after the donor ends major financial managerial and technical support politically instigated projects face challenges of sustainability due to the politicians occupancy period in the elected position a big percentage of these projects end up failing and others pick at a slow rate the study assessed factors that contribute to sustainability of county project the case study for this research was the oparanya care system a program dubbed afya ya mama na mtoto in kakamega county that was developed with an aim of reducing the high infant and maternal mortality rate and other cases associated to poverty that mostly cause death to women and children during and after child delivery the research design used was crosssectional evaluation survey that evaluates a specific case study the target population for this study included the project implementers and project beneficiaries data analysis and presentation of findings was carried out using statistical softwares including spss and microsoft excel the quantitative data was presented in form of pie tables correlations for the variables were done and results presented in a tables from the findings the effect of the economic pillar could be seen from the increase in employment opportunities and also increase in the government revenue due to the cascading effect of the community having more income leading to increase in purchasing power the program had reduced the maternal mortality rate as well as improved the community health and safety nevertheless the project is still on going and the county still has plans to increase the number of facilities further analysis disclosed that majority of the stakeholders who influence the project sustainability more were the community the correlation coefficient r between the independent variables and project sustainability showed a positive relationship consequently based on the given data the study concludes that the economic social and resource pillars have a positive effect on the sustainability of projects

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introduction the development of tourism today faces different challenges particularly due to the covid19 pandemic demands for physical distancing and the risk of virus airborne transmission have made people reluctant to travel to closed spaces as a result extensive outdoor tourism is in demand nowadays on the other hand tourists continually pursue more active involvement and direct interaction with local people it has been one of the main reasons for developing creative tourism creative tourism which is frequently linked with urban tourism is an effort to revitalize certain parts of urban areas through cultural regeneration presented in a rather innovative way to attract tourists to some extent creative tourism may also occur in the urban areas marginalized parts precisely creative tourism initiatives in the slum area for example have frequently depended upon external stakeholders rather than the local community an investigation is needed to explore the role of social capital in ensuring the sustainability of this type of creative tourism once external stakeholders stop the assistance the last decades have been associated with the emergence of the creative tourism phenomenon in urban destinations in particular the development of the village improvement initiative as a part of creative tourism has involved parties other than the government however there are still limited studies that review the extent to which this village can survive without government assistance the idea of creative tourism in many ways in asia has grown in recent years asean members have introduced creative tourism in the region but other countries have developed various methods for establishing ties between tourism and creativity in undertaking creative tourism two broad approaches can be identified the relatively topdown approaches to creative tourism development such as in china and south korea and bottomup approaches to involving local communities such as thailand and indonesia forina lestari anna karenina anthony p nasution cultureled regeneration and creative tourism development in indonesias city slums some findings from tangerang city in indonesia informal urban settlements or kampung have been extended to include any informal settlement areas in the city during its development most of them were absorbed by the rapid expansion of urban areas one notable thing is the remarkable capacity of kampung to absorb the spillover population of expanding urban areas kampungs particularly in java typically occupy about 60 percent of a citys total area are close to the city centers and provide settlement for more than threequarters of the people urban villages in indonesian cities can be traced back to the 1980s due to increasing economic development for a long time the existing villages are now surrounded by new buildings relative to the larger communities compared to modern housing most urban villages or kampungs are unstructured unorganized and informal kampung comprises a group of houses that are part of the city residents have limited access to public services such as clean water protection and waste management and they also have to look for a solution on their own its location in general is close to the main street and tends to be a slum therefore poverty and low quality of life are common features of kampung in contrast the community of kampung has a robust social character known as the traditional javanese characteristic of rukun and gotong royong tauran also adds that kampung refers to a group with kinship relations solidarity inclusion and support each other as a social structure recent efforts have improved these villages nowadays with the support of a large community group kampung created public spaces with a minimum budget the government private sector and professional artists supported kampungs in creating a lively and livable environment based on the background mentioned above this study attempts to unravel the phenomenon of creative kampung and what strategy is needed to ensure its sustainability several pieces of research have been undertaken in this direction but most were done on a single case study on the other hand this research also provides an overview of multiple study cases and draws a general conclusion such a conclusion is expected to benefit other regions in undertaking the proposed strategy additionally many studies focused on tourists perspectives and lack of consideration of the process of producing creative tourism this study also focuses on the contribution of residents since it may ensure the sustainability of creative tourism method this study employs descriptive analysis with a qualitative approach a series of indepth interviews is carried on in six kampungs in tangerang city representing other kampungs generated by the literature readings a total of seventeen people were interviewed some questions are about what changes have occurred in the village and who is driving the change besides literature reading is undertaken using the assistance of publish or perish software twentytwo articles on creative kampung in indonesia were analyzed using the software the initial keyword used is creative tourism searched in both google scholar and scopus the keyword creative kampung is used in google scholar to get more results in the local context these twentytwo articles were used to see the general view of the development of creative kampung in indonesia the results of the interviews and literature review from publish or perish are then coded using nvivo12 software it eventually led to three significant dimensions of kampung transformation in which efforts of stakeholders are undertaken to develop creative kampung result and discussion three dimensions of improvement in indonesian creative kampung indonesia is the fourth most populated country today with more than 260 million inhabitants indonesia is one of the countries with the highest urbanization rates in asia on the other hand slum is also a significant problem for the country slum settlement is a social problem in indonesia that is difficult to solve in 2019 it was recorded that the slum area reached 87000 hectares various efforts and programs have been made to overcome them however there are still many low settlements on almost every city corner accompanied by disorder in community life in urban areas the most frequent complaints regarding these poor settlements in the low quality of the environment inadequate facilities infrastructure and building conditions solid and irregular poor environmental health and sanitation low education level lowincome level and high social vulnerability the reason for a village becoming a slum can not be separated from the awareness of its inhabitants concerning their environment the habit of littering throwing garbage directly into the river and low public awareness of the importance of protecting the environment has become difficult social habits to eliminate slum settlements therefore are seen as one of the crucial problems in urban areas this study analyzes the development of the creative kampung as a tourist destination from several dimensions 1 the physical dimension referring to the physical development of kampung which some manifested in colorful or rainbow kampungs 2 the environmental dimension referring to various efforts to improve the environment and 3 social dimension referring to multiple forms of attractions and the social life of the community figure 2 six kampungs location in tangerang city physical dimension a clear example of how art can have a physical impact was created in many creative kampungs on java island indonesia kampung or urban villages situated in the city center in these areas the wall is a decoration and productive space the community process has transformed a place into a creative space and encourages residents to explore their local potential thus creating a place of identity each of the kampungs in tangerang city preserves its unique identity such as the kampung with the grape yard in kampung anggur sari the kampung with the hydroponic system in kampung cimone the kampung with scenic view in kampung pinggir rawa and kampung with pink buildings in kampung pink all of the six kampungs observed in tangerang possess a significant change in terms of physical dimension a similar pattern is also observed in other parts of kampung on java island based on the literature for example kampung pelangi or rainbow villages is a village with a colorful concept to transform the slum village into a cleaner and healthier tourist destination some of the villages are located on the banks of the river in east java and there are kampung jodipan malang kampung kroman grasik kampung sungai kalilo banyuwangi and kampung kenjeran surabaya in central java there are bejalen ambarawa tourism village wonosari color village in semarang and several other cities such as lubuk linggau and teluk seribu village in balikpapan besides painting walls or murals is one of dago pojoks in bandung city west jawa has creative inventions as an appreciation of art and imagination visitors visiting the vibrant village may also participate in a mural game it is a fresh trend in tourism facilities as tourists can show their imagination on the wall environmental dimension densely populated settlements can be modified with creative strategies by turning weaknesses into strengths several environmental programs can change an unclean environment due to residents unhealthy behavior regarding waste management establishing greywater treatment is necessary to maintain a sustainable clean water requirement that dwelling shall set up a treatment for greywater to help provide clean water this improvement program contributes to the environment in many ways such as wwtp used by local people in kampung maspati to water plants or wash vehicles the residents of kampung maspati can save money for monthly water payments as clean water additionally the composter in kampung maspati helped the city reduce waste and can be used as fertilizer the application of the waste bank is very profitable for the kampung because the community can save through nonorganic trash such as plastic bottles to be collected and sold finally implementing urban farming in the kampung maspati contributes to food security as kampung can provide vegetables for selfconsumption and save up to ± 50000 rupiahs monthly another example comes from kampung gandhi which made attractive living environments ranging from planting rows of fruit trees and vegetables and recycling plastic waste to other products kampung jambangan in surabaya is another positive example of creating a healthy green and clean ecosystem they have planted many trees and flowers and bred birds to conserve the world of nature in the built environment residents also organized garbage recycling such as plastic bottles iron or aluminum bottles and paper another example is kampung dago pojok bandung the visitorstourists will be provided with information and participate in activities about urban agriculture in the kampung they use unused urban land to be converted into productive green farming land run by communities to generate income social and cultural dimension the social and cultural dimensions can be demonstrated by the attractive arts created and performed as critical programs for creative kampung development in tangerang for example all of the six kampungs observed were initiated by the residents these residents have frequently worked together to keep their environment clean kampung inovasi cimone for example has been known for the activities undertaken by the female residents group in providing help for seed plantations this activity has been empowering local youth thus decreasing the crime rate in the area after sometimes then assistance was proposed to external stakeholders such as business owners and the government some of the assistance were paint toilet provision souvenirs etc in the literature another example is found in dago pojok the kampung has developed local traditional sports musical art and theatrical art such as reog and gondang art pencak silat jaipong degung kuda lumping karinding calung art and others komunitas taboo as the local community group performed some of the performing arts through the campaign komunitas taboo is helping to restore and raise local art to exist and generate economic value with its attractiveness not only traditional art but komunitas taboo also performs theatrical arts that reflect their understanding of the social economic and political environment that is taking place in indonesia through collaboration with young people mostly university students to preserve the heritage of sundanese art and culture komunitas taboo organizes festivals such as the kaulinan budak festival and the mural festival factors related to the sustainability of creative kampung having discussed the aspects of creative kampung in previous part this part further explores factors affecting the sustainability of creative kampung three factors are identified stakeholder roles social capital and economic value these factors are identified using nvivo12 stakeholder roles the role of stakeholders has been proven to influence the sustainability of creative kampung in particular combining a bottomup approach and external support is the key to sustainability in this part three stakeholders have been identified the government the private sector the academicians and the community 1 government roles one notable program carried on by the national government is developing a slumfree program collaboration platform called kotaku the program accelerates the handling of slum settlements and builds a collaborative platform by increasing the local governments role and the community the kotaku program is implemented in 34 provinces spread over 269 districtscities that have aimed not only to change the physical structure of the settlement but also to maximize sdgs carried out from 2000 to 2015 it would also guide achieving the global goal of sustainable development in 2030 one example of implementing the urban renewal program is the kampung deret program introduced by the provincial government of dki jakarta on the other hand the government of bandung attempts to create as many creative villages as to provide ample opportunities for tourists now there have been 30 villages created and the government is targeting one village for each subdistrict in the case of tangerang the improvement of kampung initiated by the residents has been supported by the government in various forms such as training manpower paints etc this is also the case in surabaya where the local government has also been active in improving the environment and economic quality such as through the green and clean program in semarang the mayor of semarang 2017 brought several innovations eventually turning the slums into clean lovely organized and attractive areas the semarang city government undertook the thematic village program to enhance the communitys capacity to increase awareness insight and basic skills in preserving its neighborhood it enables them to participate in the development and foster selfreliance in initiatives and capabilities as the earliest designated village kampung batik is batik thematic village from 32 urban thematic villages that underwent significant changes the town formerly known as the slum area and the criminal hiding place and now known as a beautiful village and has become one of the tourist destinations in semarang city stimulant from the city government aligns with community participation in village management by relying on communitybased management forina lestari anna karenina anthony p nasution cultureled regeneration and creative tourism development in indonesias city slums some findings from tangerang city 2 private role the involvement of the private sector in the creative kampung initiative has been mainly to support activities undertaken by the community this involvement aims to increase the companys positive image in public an example of this involvement was the provision of paint by pt indiana paints in malang to paint buildings and the provision of support funds to develop creative kampung in banjarmasin a consortium named bccf provided other forms of support to channel grant funds as a stimulus to develop creative kampung in bandung the funds to some extent could also be used for other activities such as capacity building infrastructure improvement and festivals 3 academics role academics triggers transformation in the creative kampung of the slum area in malang the initial initiator of the change of kampung warna is muhammadiyah malang university the team was inviting the community to carry out the idea together the idea was then communicated for a joint implementation to all rukun warga and rukun tetangga another example in bandung city rahmany and djajadiningrat argue that the creative kampung initiative has led to an exciting mix of participants including the government industry local people and visitors first the initial strategy was initiated by the bandung institute of technology which focused on creating images and then developing connections with other networks and stakeholders an annual festival could bring many visitors into the area including several international tourists which is one of the essential drivers of creative tourism the organization of the festival emphasizes the importance of public participation the festival is held to stress that visitors must interact with public space at the campsite 4 the community roles the role of community shown in the case of creative kampungs in tangerang city as mentioned before was due to the awareness of the local people they significantly contribute to designing attractive focal points for tourists or visitors in particular the residents ensure visitors can learn and do something during their kampungs visits the residents have provided training unique and personal experiences may affect visitors satisfaction and increase their chance to revisit the kampungs the role of the community is also shown in kampung maspati as the winner of the best of the best kampung competition in the green and clean category in 2015 this camp was once a slum camp but local communities have improved the quality of the campsite over time the local community is gradually trying to improve the environment quality and its economic limitations through its awareness of protecting the environment collaboration between the local government local private ngos and mass media such as jawa pos and radar surabaya is one of the surabaya green and clean collaboration programs kampung tridi pointed out different paintings and graffiti on the houses and created a 3d impression of kampung tridi paintings as the painting began an initiative was created to clean up the area the local artists group was responsible for maintaining the paintings and ensuring that old paintings were renewed every 34 months jodipans and kampung tridis stories attracted national and international attention through social media according to tripadvisor this destination is one of the 7 top activities in malang and has become a tourist destination today it is one of indonesias new tourist destinations another example in kampung pelangi in sidoarjo involves the community targeting the most significant number of housewives who do not work it is supported by groups that can support youth organizations and housewife organizations the strategic stages in this process are forming creative ideas realizing and strengthening the support system providing space for creative activities and evaluating the process batik training shibori is one of the activities the community service team held and collaborated with umkm grand batik from sidoarjo to provide dyeing batik training it can be seen that human resources are a critical component of tourism growth which defines program execution and tourism quality in a particular region for example nowadays the tourism kampung of dago pojok is organized by pokjawis this group includes nature tourism mural tourism working group art tourism working group urban farming working group festival workgroup and art tourism working party with the support of lkm taboo komunitas taboo creates annual festivals such as a musical show certain traditional events competitions for drawing bazar rakyat and other creative activities the increasing attractiveness of the creative kampung comes from initiatives undertaken by nongovernment stakeholders such as educational institutions communities and private parties these stakeholders play a crucial role in making kampung one of the tourist destination areas this study found that the strength of collaboration is crucial in building the creative kampung initiative social capital this research considers social capital to be one source of urban village communities to perform collective action informal and formal alliances and bridge and bonding networks while the urban kampung village society has a low environment and sanitation it appears to have an excellent social life most of the community is an indigenous person who has lived there for a long time the community has social and cultural values that are part of the structure of the community which still has community assemblies congregations and community organizations the longstanding tradition of reciprocal cooperation represents the peace of society there is robust community engagement whenever a civic activity happens in the case of kampungs in tangerang social capital became the key to creative tourism sustainability social capital such as trust helping each other kinship and working together stimulate the community to undertake kampung improvement activities actively several followup strategies could be employed such as retaining the younger generation in the villages with new business opportunities intensive workshops training in improving awareness and community skills and maintaining the collaboration between stakeholders the historical potential cultural heritage and unique kampung traditions bear social and cultural values for example kampung surabaya a former town has unique social structures and traditions cangkrukan and adu burung dara which still last now cangkrukan is an expression used for the social activity of residents cangkrukan people gather to socialize at a post office or at a coffee stand at night it could be anyone people who do free chat are usually men but women do it today they chat play cards play chess and eat food together from dusk until dawn so that they can watch the kampung so it is safe the method is proven effective and kampung surabaya won second place in the safe kampung competition held by the surabaya city government in sum the social capital of the community should be strengthened through building community capacity creating local pride and selfsufficiency community engagement and stakeholder collaboration developing new ways to work across the value chain of tourism through creativity and innovation and empowering leaders to share a communitybased approach to tourism developing meaning to engage a wide range of stakeholders is therefore crucial economic value the values of the economy may be derived from the inhabitants creativity for example there have been initiatives to create valuable handicrafts to overcome household garbage forina lestari anna karenina anthony p nasution cultureled regeneration and creative tourism development in indonesias city slums some findings from tangerang city problems such initiatives have opened economic opportunities first as one of its traditions kampung surabaya is also regarded as the kampung of arts and crafts they won the green and clean competition by making a gate from plastic bottles of mineral water they also made bags purses mats flower decorations and wayang out of detergent aluminum foil packages apple packages drink ssnacks package cartons soft drink packages etc the handicraft is then sold outside kampung to people who want it other examples are from the dago pojok tourism village in bandung city it has the potential of the cottage industry produced by local communities such as recycled paper products art painting kampung snacks painted tshirts batik carved wood and other creative handmade products in this place visitors are not only able to buy authentic souvenirs from dago pojok but can also participate in the process of handicraft production second in kampung maspati they offer visitors cultural performances traditional food crafts traditional games and hospitality the group leader and women with no jobs ran the program this program created the residents income enhanced unity among the kampung residents and gave residents a sense of pride in their kampung most kampung village is a slum area with dense populations and jobless people far from prosperity there were diverse occupations of its surrounding people such as pedicab drivers housemaids workers on the flea market and many more but most were jobless with the establishment of creative kampung there are many improvements to job opportunities the activities include decorating the entrance with flower arrangements and changing mural painting once a couple of months the results of this study have confirmed the importance of placemaking practices in the form of creative kampung in particular placemaking in the tourism context has positively impacted both places and their inhabitants further this study also found stakeholder collaborations significance and positive effects stakeholder collaboration improved the quality of placemaking and local identity and further maintained the sustainability of the place in the physical social and economic dimensions this analysis showcases the increasing importance of shaping creative development strategies and forms within them to ensure this creative villages sustainability in addition to strengthening the role of crossstakeholders it is also necessary to support the community when outside stakeholders are no longer helping the community can independently develop its area by sharing innovations and maintaining economic value and environmental effects heritage service quality and participatory experience are crucial in constructing creative tourism to ensure sustainability it is crucial to use their endogenous resources capacity building and bottomup creativity in this way they can avoid the creativity trap of following generic creativity models and develop modes of creative tourism more appropriate to their size and capabilities the lesson learned is no model fits all so the approach should be adapted to the local capabilities and characteristics finally kampung in indonesia is not only a residential area but also a dynamic residential area and homebased entrepreneurs several kampungs produce food household goods and handicrafts in their homes and then sell them they can also organize the association with different levels of education occupation and social backgrounds the remarkable thing is that they are transparent and quick to formally and informally collaborate with other classes they are agile in creating a network with government businesses ngos schools universities and communities therefore their capacity contrasts with the kampung peoples story which is portrayed as uncivilized and incompatible with urban culture conclusion and recommendation research in slums has been numerous in numbers however it is crucial to stress that slum upgrade programs affect physical conditions and enhance social wellbeing and local networks other stakeholders have also noted that empowering people in the areas reduces social inequalities rather than the government in particular creative kampung tourism comes as a solution to problems derived from urban development indeed twothirds of the citys population live in the kampung most people with low and middle income this study confirms the importance of a comprehensive approach in developing kampung areas in particular recognizing different conditions potentials and drawbacks in each kampung could contribute to a more robust understanding of local identity and pride prosperity social connections and quality of life this in turn would result in the sustainability of creative kampung tourism programs undertaken by the residents creative kampung tourism has essential implications for tourism placing creativity in specific local contexts rather than seeing it as a global panacea allows for more balanced approaches to integrating topdown and bottomup initiatives the content of actions and courses in kampung was associated with painting crafts dance or gastronomy elements they attempted to share and

tourism has been in the spotlight recently especially in urban slum areas many studies have reviewed slum areas however transforming slums into creative tourism villages or kampungs is a new phenomenon that emerged in urban slums in indonesia creative kampung in particular is a form of tourism that changes the slum area into a tourist destination this study aims to explore the extent of the creative tourism kampungs sustainability and the role of stakeholders in ensuring the sustainability of this creative tourism village this study employs descriptive analysis by combining indepth interviews and literature analysis to unravel creative kampung in practice this study found that the kampungs transformation can be seen in physical social and environmental dimensions moreover this study also outlines an appropriate strategy to ensure the sustainability of creative kampung stakeholders collaboration to maintain social capital and economic value is proposed to sustain the creative kampung initiatives it is because creative kampung provides a way to preserve culture and at the same time boost the local economy therefore transforming slum villages in many cities into creative tourist villages is one of the solutions for dealing with urban slums

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introduction a healthy society reflects the prosperity of a country therefore health is a fundamental right of all citizens and health promotion is integral to health care according to the definition of health it is a condition of whole physical social and mental wellbeing rather than just the absence of disease or infirmity disease is also a part of excellent health as it is more consistent with poor health in recent years the ability to live a socially and economically useful life has been added to the notion of health the federal ministry of health has stated clearly that the protective preventive restorative and rehabilitative care provided to every citizen of the nation within the limits of available resources is the primary focus of the national health policy this will ensure that people and communities can live productive fulfilling lives and contribute to society the pursuit of perfect health by man is a social and cultural constant this may be explained by the fact that human existence and the achievement of specified objectives and aspirations on earth both depend on good health the utilization of health facilities is essential if man is to live and operate to his full potential because of this societies have evolved many types of health care systems over time to take care of their citizens however issues with the populations health quality the equitable distribution of healthcare facilities across social groups and peoples access to or use of these facilities particularly among the underprivileged continue health care administrators frequently focus on enhancing the standard of staff training treatment methods supply availability and environment of healthcare institutions although these initiatives are crucial many of the populations access challenges are not necessarily resolved by them there are frequently enough health services available yet few people use them concerns about the availability of services their physical and financial accessibility understanding of those resources instruction on how to use selfand practitionerprovided services most effectively and cultural treatment norms are all equally relevant in nigeria the three levels of governmentfederal state and localall have a continuous list of expenditures they must make for health services in nigeria the private sector also plays significant roles in the provision of healthcare these include private for profit and private not for profit healthcare facilities run by corporations nonprofits and religious organizations despite rising public spending on the delivery of modern healthcare the usage of health services has remained low in nigeria this shows that before the decision to seek therapy and the subsequent arrival at a clinic a plethora of intricate and potentially perplexing options interact even when the ailment would be best addressed in public health facilities those factors are frequently compelling enough to shift attention to other forms of therapy it follows that a detailed understanding of the elements involved in the usage of health services is necessary to provide patients with accessible and affordable healthcare objectives of the study the main objective of this study is to examine the determinants of demand for health care services by rural households of akinyele local government the specific objectives are • to examine the relationship between the sociodemographic characteristics of the respondents and the demand for health care service in akinyele local government • to examine the major socioeconomic factors that affect or determine use access to health facilities and services by residents of akinyele local government • to examine the relationship between cost of drugs and the demand for health care service in akinyele local government literature review 2 1 theory of demand the law of demand can be used to explain consumer desire for goods and services in accordance with the law demand for a commodity or service decreases as its price rises all other things being equal in contrast the quantity of a good or service required increases as the price of that good or service decreases this suggests that all other things being equal the quantity requested and the price of a good are inversely connected schedules of demand are used to verify the law of demand a demand schedule displays the quantities of a product that were desired at various prices at a specific time and location it might be for a specific person or a certain market the quantity of a good or service that a buyer is willing and able to buy at specific pricing at a given moment all other things being equal is referred to as demand figure 31 which follows further exemplifies this health belief model irwin m rosenstock godfrey m hochbaum s stephen kegeles and howard leventhal are the authors of the health belief model according to hbm a persons tendency to engage in a particular healthseeking behavior will be predicted by their perception of their own risk of contracting an illness or disease and their confidence in the efficacy of the advised health behavior or action with the premise that the two elements of healthrelated behavior are 1 the desire to avoid sickness or alternatively get well if already ill and 2 the belief that a particular health action would prevent or cure illness the hbm is based on psychology and behavioral theory in the end a persons course of action frequently depends on how they see the advantages of and obstacles to engaging in healthy activity the hbm consists of six structures the first four constructions served as the hbms founding principles the final two were included as knowledge of the hbm increased the concept presupposes that an individuals contribution to health and illness prevention is central to four fundamental considerations which include  the individuals perceived susceptibility to disease  the individuals perception of illness severity  the individuals rational perception of benefits versus cost  the individuals cue to action like the media friends and family the third and fourth factors might act as the basis for an explanation of this investigation cost savings and social familial and media pressure can have an impact on how often people use herbal remedies it is impossible to overstate the influence that friends and family have on our behavior when it comes to seeking health additionally it has been proven that the media has a significant impact on how people behave when seeking out health care the theory has come under fire for failing to take emotions into account when explaining healthrelated behavior fear for instance is thought to have a significant role in motivating people to seek out healthy behaviors empirical review with the help of three study questions and a crosssectional survey design nnonyelu and nwankwo investigated the factors that affect varying levels of access to healthcare in five states in southeast nigeria 1 the study discovered that characteristics such as degree of education gender patriarchal social structure rural habitation poverty religious and cultural attitudes regarding particular diseases and location of health facilities among others have a significant impact on access to health services it was advised that in addition to providing health services institutional arrangements and widespread public education be made to address the various social barriers preventing southeast nigerians from accessing and fully utilizing health services in rural cross river state nigeria nkpoyen et al examined how health capital and poverty reduction related 2 the results showed a substantial relationship between the reduction of rural poverty and the health capital variables of health care demand accessibility and affordability of health care services and the percentage of household income devoted to health care it was determined that changes in physical and financial access to health independent of changes in rural poverty would have only a little impact on rural residents decisions about their health care aina et al looked into the factors that influence rural households in nigerias ekiti states demand for health care services 3 the empirical analysis revealed that among all the explanatory variables employed sex marital status household expenditure and waiting time were identified as significant factors affecting demand for health care services among rural households sourcing health care services from dispensaryprimary health care private hospitalsclinics patient medicine stores general teaching hospitals and traditionalspiritual homes the basic category was patient medicine retailers in ogun state southwest nigeria omonona et al looked at rural households access to and usage of healthcare services 4 structured questionnaires were used to gather primary data the findings revealed that the respondents had an average household size of 8 people and a mean age of 46 the majority of responders lacked a formal education and farming was their primary occupation 58 percent of respondents reported having access to health care services while only 4250 percent actually used them the majority of responders travel 59 kilometres before visiting a medical facility according to accessibility indices the research area has unequal access to new medical facilities in oyo state nigeria olaiya and owoeye examined the impact of health insurance on the demand for medical treatment 5 the demand for health insurance in oyo state is precisely determined by the study the chisquare test and descriptive statistics were used in the study according to the report there is a substantial correlation between age group and payment method with older persons using health insurance at a rate that is 220 higher than that of other women the demand for healthcare services and related factors among patients in the community of tsegedie district northern ethiopia were explored by tsegay et al 6 in northern ethiopia a communitybased crosssectional survey was carried out between march 1 and march 30 2016 according to the report the majority of patients in the tsegedie district sought access to contemporary healthcare the demand for health care services was found to be substantially correlated with the accessibility of the facility user costs household educational level quality of care and sickness severity instead of relying on user fees outofpocket expenses should be replaced by prepayment plans like communitybased insurance and effective health information dissemination initiatives should be strengthened to raise awareness of contemporary treatment 2018 looked into the factors that influence demand for healthcare 7 the findings revealed that a total of 327 articles from the databases and nine more from other sources were initially searched duplicate articles were eliminated 233 papers were then subjected to primary screening based on their titles and abstracts following this 20 papers were ultimately picked and included in the final literature search after 75 articles received a secondary evaluation for eligibility the demand for healthcare related to the use of healthcare based on the types of healthcare providers and services offered health status and also health spending age gender ethnicity education occupation household income and size marital status family size health status health problems and duration of those problems medical insurance coverage medical and nonmedical costs or prices health expenditure distance to provider and waiting time were the factors that determined the demand for healthcare zamzaireen et al the 2019 study by rifkatu and olanrewaju looked at the factors that influence the use of prenatal care in nigeria economic and noneconomic factors were statistically significant at 1 and 5 respectively according to the results of the twopart model analysis income pricing and supply factors are a few examples of economic variables wealth employment health insurance distance and travel to health facilities no provider and no female provider were used to gauge these factors age education birth order location ethnicity marital status and religion were noneconomic factors research methodology the theory of demand serves as the foundation for the studys theoretical framework the law of demand can be used to explain consumer desire for goods and services in accordance with the law demand for a commodity or service decreases as its price rises all other things being equal in contrast the quantity of a good or service required increases as the price of that good or service decreases model specification based on previous literature and consumer demand theory this study propose a theoretical model to explain the determinants of demand for health care services df ………………………………… where 1 above shows the crosstab of the socioeconomic characteristics of the respondents in relation with the demand for health care service the result revealed that 42 of the respondent that demanded for health care service were male while 58 of the respondents that demanded for health care service were female about 355 of respondents between the age of 20 and 30 years demanded for health care service 40 of the respondents between the age of 31 and 40 years demanded for health care service 17 of respondents between the age of 41 and 40 demanded for health care service while only 75 of the respondents above 50 years demanded for health care service on the marital status of the respondents that consumes rice 375 of the single respondents demanded for health care service 515 of the married respondents demanded for health care service 45 of the divorced respondents demanded for health care service and 25 of the widowed respondents demanded for health care service while 4 of the respondents that demanded for health care service were single parents regarding the level of education of the respondents who requested health care services 2 of the respondents who demanded health care services had no education 15 of the respondents who demanded services had a primary education 19 of the respondents who demanded for health care services had a secondary education 24 of the respondents who demanded for health services had a tertiary education and 475 of the respondents who demanded for health services had a higher education regarding the respondents religion 35 of them are muslims 34 of them are christians and 1 of them are traditionalists of those who demanded health care services the majority of respondents are christians additionally 155 of respondents who demanded health care services were students 365 were business owners 275 were government employees 19 were owners of private businesses and 1 are farmers on the average monthly income of the respondents that demanded for health care service 125 of the respondents that received less than 10000 naira demanded for health care service 475 of the respondents that received between 10001 and 50000 consumer rice 235 of the respondents that received between 50001 and 100000 naira demanded for health care service while 165 of the respondents that received above 100000 naira demanded for health care service relating to the family type of the respondents that demanded for health care service 855 of the respondents that demanded for health care service have a nuclear family while 145 of the respondents that demanded for health care service have a polygamous family also 55 of the respondents with one person in their household demanded for health care service 14 of the respondents with 2 persons in their household demanded for health care service 285 of the respondents with 3 persons in their household demanded for health care service while 52 of the respondents with more than 3 persons in their household demanded for health care service relating to the tribe of the respondents that demanded for health care service 55 of the respondents that demanded for health care service are hausa 21 of the respondents that demanded for health care service are igbo while 735 of the respondents that demanded for health care service are yoruba the respondents access to healthcare is displayed in table 2 above 135 of respondents strongly disagreed that they were unable to visit the health center on a regular basis due to high medical costs while 17 of respondents disagreed they were unable to visit the health center on a regular basis due to high medical costs of the respondents 435 strongly agreed that they were unable to visit the health center on a regular basis due to high medical costs about 22 of the respondents strongly agreed that the inability to obtain convenient appointment times is a barrier to health center accessibility 245 of the respondents agreed that the inability to obtain convenient appointment times is a barrier to health center accessibility 31 of the respondents disagreed that the inability to obtain convenient appointment times is a barrier to health center accessibility while 225 of the respondents strongly agreed that the inability to obtain convenient appointment times is a barrier to health center accessibility about 25 respondents strongly agreed that long wait times make it more difficult to schedule and keep a medical appointment 215 agreed 295 disagreed and 24 did not agree with this statement approximately 165 of respondents strongly agreed that they travel farther to access various points of the healthcare delivery system while 225 agreed however 32 of respondents disagreed that they travel farther to access various points of the healthcare delivery system and 29 of respondents strongly disagreed that they do about 31 of respondents strongly agreed that the healthcare facilities in their area are small and frequently offer limited services 26 of respondents strongly disagreed 265 of respondents agreed 315 of respondents disagreed and 26 of respondents disagreed but did not strongly disagree that the healthcare facilities in their area are small and frequently offer limited services the regression output above shows that price of healthcare service the cost of drug educational qualification and the distance to health centres are statistically significant in determining the demand for health care services among the people in akinyele local government area while income age and gender are statistically insignificant as price of healthcare services cost of drugs and distance to health centres are significant at 5 level of significance education qualification is significant at 10 level of significance regression the correlation between the variables reveals a positive relationship between the demand for healthcare services and the cost of pharmaceuticals income age and educational level this means that the demand for healthcare services will rise by 018 009 003 and 019 respectively for each percentage increase in the fact that the healthcare facilities in their area are tiny and frequently offer limited services additionally because the demand for healthcare services is inversely correlated with the cost of healthcare gender and distance the demand for healthcare services will decrease by 016 011 and 020 respectively for each percentage rise in each of the variables this result is consistent with studies by hanson yip and hsiao as well as ali and noman which demonstrate a negative relationship between the cost of healthcare and demand 910 the patient receives the most comprehensive medical care possible thanks to a decrease in the cost of healthcare and unequal consulting fees charged by private providers the results of ali and nomans study show a favorable relationship between income and health care demand and education therefore using a health awareness campaign as a standin for education may lead to an increase in demand for health services discussion of finding the study looked into the factors that influence rural families in the akinyele local governments need for health care services two hundred questionnaires were employed to collect certain important and pertinent data regression analysis percentages and frequency distribution statistics are some of the techniques employed this frequency and the percentage allow us to understand how the respondents feel about the queries posed and answers provided the regression analysis was utilized to determine the variables sign and size as well as their significance the regression analysis shows that price of healthcare service the cost of drug educational qualification and the distance to health centres are statistically significant in determining the demand for health care services among the people in akinyele local government area while income age and gender are statistically insignificant as price of healthcare services cost of drugs and distance to health centres are significant at 5 level of significance education qualification is significant at 10 level of significance conclusions a basic human need is for health the level of population health and how equally access to healthcare is distributed among social groups can serve as valid indicators of a societys level of progress the positions of this study are that healthcare service the cost of drug educational qualification and the distance to health centres are great determinants of healthcare demand in akinyele local government area recommendations the following recommendations are made based on the studys findings 1 • the government should make critical medications and healthcare services available for free or at no cost to the public at public health facilities with a monitoring team to assure efficient implementation • health facilities should be placed closer to the populace especially in rural regions with little regard for political or class factors that can hurt the underprivileged masses • the government should offer employment possibilities so that people can get money to take care of their health by making proper use of the local medical facilities data availability the corresponding author can provide the datasets that were gathered andor analyzed during the current investigation upon request the accompanying authors are in complete control of the data used in the study and are accountable for their accuracy and integrity

the study looked into the factors that influence rural families in the akinyele local governments need for health care services two hundred 200 questionnaires were employed to collect certain important and pertinent data regression analysis percentages and frequency distribution statistics are some of the techniques employed this frequency and the percentage allow us to understand how the respondents feel about the queries posed and answers provided the regression analysis was utilized to determine the variables sign and size as well as their significance the regression analysis shows that price of healthcare service the cost of drug educational qualification and the distance to health centres are statistically significant in determining the demand for health care services among the people in akinyele local government area while income age and gender are statistically insignificant as price of healthcare services cost of drugs and distance to health centres are significant at 5 level of significance education qualification is significant at 10 level of significance

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introduction the province of québec has a vast territory and a small population in comparison to many european countries population is concentrated in urban regions and for many years québec has been struggling with demographic movements and rural exodus correspondence concerning this article should be addressed to stéphane allaire email these downward movements have important consequences for village schools and their communities for instance some schools are threatened of closing because of population decrease considering the interdependence between a school and its communitys vitality when such a situation occurs the whole community suffers indeed whose parents would want to buy a house in a rural community where there is no school for their children however when a small school remains open its small size may become a challenge to insure a learning environment of quality the new learning sciences have shown the importance of social interactions in a learning environment communication and collaboration abilities are included in the various lists of twentyfirst century skills for citizens of that evolve in knowledge societies and knowledge economies in this paper we first provide some background to this study including a description of the networked learning environment that is being fostered secondly we present the methodology used to document advantages of collaboration between schools from both teachers point of view and parents representations of such a model thirdly we communicate results of data collection and analyze teachers and parents representations of the remote networked school background the rns initiative was born of a desire to maintain small schools in remote villages in quebec to address rural exodus and prevent the closure of these small schools but also to provide quality service related to teachers professional development and childrens learning this initiative began in 2002 with three participating sites and a knowledge transfer organization after searching for best possible uses of icts in small schools we chose what we considered to be a powerful electronic forum we chose it on the basis of its affordances for learning and knowledge building that support written asynchronous discourse and a videoconferencing system that permits synchronous verbal discourse kf won the award for best collaborative tool at the 2005 computersupported collaborative learning conference in taiwan teachers and students were told to use the same tools for their professional development and student learning and then the initiative began by having them use these tools we wanted to develop a model that would allow small classrooms from different schools and regions to work together and to hopefully enrich the learning environment through social interaction a proof of concept resulted from phase 1 and phases 2 3 and 4 followed to implement the model on a larger scale now in its fifth phase the rns model has taken root in more than twenty school districts and in over 120 rural schools some school districts are still in the early stages of implementation whereas others have institutionalized the model conditions of innovation played an important role in the way the model has spread school involvement in a small school there may be two three or four teachers teacher participation in the rns initiative is voluntary the school principal often manages more than one small school for each school large or small there is a school council and parents as well as teachers are represented the school councils decision to participate in the rns initiative is critical and so is the school districts technical administrative and pedagogical support in most active schools our own participating observation of the initiative led us to note that there comes a time when nonparticipating teachers may feel some pressure from their colleagues to join in on this project students are also likely to ask for it as they generally enjoy the hour devoted each school day to rns learning activities each school is considered a learning community we speak here of community because participants have a shared goal teachers and students join together and outside classrooms and experts bring their contribution to the initiative community involvement the role of all stakeholders is crucial including parents local experts and social leaders a strong partnership between these key players often develops as a consequence of this educational project having been implemented in a few cases small town leaders have played a key role regarding the promotion of the rns 1 a great number of the rns schools are in a deprived socioeconomical environment according to the scale by which the ministry of education conducts activities and analyses families low income has a significant impact on student perseverance in school until graduation the educational level of parents also affects childrens schooling et al argued that what is important is not so much what parents are but rather what they do parental participation takes on many forms such as homework supervision emotional support time management supervision conversation about school or preparing a child for school and welcoming him or her back interacting with the school and finally volunteering at school parental involvement deslandes in the rns parents have to agree that their children take part in the research that documents this innovation process however the childrens participation in the rns is a school decision it is a matter of pedagogy parents support is considered a factor moreover their participation is also considered a positive factor doing with students comes in parallel with doing with hisher family stated kanoute and vatzlaaroussi research shows that it is the democratic but structuring parent who contributes most to the cognitive development of the child and encourages the development of hisher autonomy there are several components in democratic parenting style praise support approval encouragement cooperation expressing affection and physical affection other authors point to the following three components of a democratic parenting style a high level of parental involvement a high degree of parental supervision and a high degree of autonomy granting how do parents perceive the rns and what do they expect from it how do they participate in the academic life of their children enrolled in an rns school what are the roles that parents play what are their responsibilities what do they do to support the rns in their community in other words what are the social representations that these parents have of the rns it is these questions that this paper addresses in addition to the teachers point of view about school collaboration promoted by the rns model methodology two poles of results are presented here 1 the advantages of collaboration between schools from the teachers point of view 2 parents social representations of the rns model and its value as it pertains to their childrens education data collection to report on the first pole we focused on teachers their sense of isolation and their own professional development experience within the rns initiative over two hundred teachers or so had responded to questionnaires over the years and at least 80 of them in a recurring manner we also conducted semistructured interviews with about 30 of these teachers for the purpose of this paper we will report results about questions that deal specifically with the way they characterize students learning experience in the rns context to address the second pole of results we focused on social representations parental participation is being recognized as an important outsideschool factor in childrens education and one linked to a number of variables including the understanding that parents have of their role their sense of competence to help their child succeed in school and invitations to participate on the part of teachers parental involvement may also depend on beliefs values expectations needs perceptions attitudes etc that the parent maintains toward the school in general and the rns in particular some educational researchers have shown the important role played by values and attitudes prejudice and stereotypes these symbolic sets can be studied separately or comprehensively with the theory of social representations the study of sr seemed appropriate here because much like abric it is recognized that the sr is an essential element in understanding the determinants of behaviour and social practices in other words each time a subject acts in the face of a phenomenon every time he says what he thinks about a phenomenon it is in its representations that he or she learns how to behave or think about the phenomenon through sr we access the modes of thought of the subjects their vision of the rns and social practices guided by these sr the study of sr offers a new voice to explain the mechanisms by which social factors affect the actual educational process and affect outcomes while parental participation may be impossible or difficult for some especially when there is no understanding of the schools inability to help their children other studies have shown that parents do get involved in the academic life of their child parental practices are grouped under five categories emotional support communication with teachers interactions between parents and adolescents on school life parentschool communication and parentchild communication semistructured interviews were conducted with 12 parents of which 5 were interviewed during phase 1 of the rns initiative and 7 during phase 5 we precise that parents are not the same and do not come from the same villages so our goal here is not to report any change or evolution of representations over time two main types of questions were considered parents representations of the rns and their expectations of the rns examples of questions asked are the following ones in your words how would you describe what goes on in a networked school what differences do you see between rns and regular schools what do you expect from the rns initiative with parents interviewed during phase 5 and considering the initiative had been implemented for a while we added two other types of questions these types covered their conception of child development and of their participation in the rns we asked questions such as the following what types of abilities do you think your child was able to further develop since taking part in an rns have you noticed changes in hisher motivation toward school grades social skills ways heshe uses icts how are you involved in your childs rns activities how could you describe your collaboration with the school data analysis we used descriptive statistics for questionnaire data interview data was searched for emergent themes and patterns our procedure was based on content analysis we read over interview transcriptions a few times and identified emerging recurrent themes our unit of analysis was the idea each time a new theme was added transcriptions already classified were read once again to ensure that their classification still corresponded to the original once all transcriptions were codified we looked for redundant themes and we adjusted our classification accordingly we skipped the step of formal quantification of statements corresponding to our unit of analysis as our goal was mainly to account for the diversity of representations and points of view results teachers perspective on the benefits of collaboration between schools teachers that feel professional isolation can go beyond schools borders to interact and share ideas with colleagues from other regions in 20072008 40 said they felt isolated before joining the rns initiative this rate dropped to 2 after engaging in their rns collaboration was judged as one of the main competencies developed in this context many advantages were stated as illustrated in table 1 collaboration advantages for teachers teachers discourse planning together considering im working in a distant school i dont have many teamwork opportunities to build learning projects with colleagues im always in my small classroom planning my schedule alone and this is a bit boring at times getting more ideas it is sure is richer two heads are better than one we often say that and now im experiencing it in regards to ideas it is richer our projects can be more ambitious because we have the opportunity to share tasks this helps a lot comparing practices we are linked to each other we feel less alone and this allows us to verify if what we are doing with kids is right or not to some extent we are guides to each other creating and enlarging a teacher network it is fun because we feel less isolated for instance we were three teachers who often worked together this year we tried to increase our network and to include new people so we are more than three sometimes we want to discuss something but we dont have time to get to the next village in rns we are able to be part of a network without travelling table 1 professional collaboration advantages from teachers perspective advantages for students teachers discourse motivation we can think about kids motivation i saw it i have students that have created strong relationships with students from distant schools i have other students who had a lot of fun with people they didnt know before at the beginning i thought it would be cold but this allowed us to concentrate on learning goals they quickly asked each other what have you found out on this topic they create friendships without being in actual contact and seeing each other benefits for learning as students have to explain things to others they play to some extent the role of teacher and i think they learn more this way it allows to experiment spontaneous communication in comparison with a wellplanned oral presentation they noticed that people from elsewhere were able to complete their ideas to enrich them worldwide opening our current project is about villages this allows kids to learn about villages that they have never had the chance to visit a student went to a tennis competition organized by the school board she recognized students with whom she spoke prior to this year my students will spend 6 years in the same classroom with the same people this is a great opportunity for them to meet and share with other people for them this is simply worldwide opening they realize there are students like them on the other side of the river that need and want to learn almost the same things they are actually learning elementarysecondary transition it creates relationships so that when the teenager graduates to the secondary level it makes it easier to introduce him or herself the school community when they arrive at the secondary level in the big school sometimes they already know up to five students it makes them more confident more secure and then the transition is easier table 2 advantages for students from a teachers perspective however collaboration is not always easy to manage especially when there is no routine installed the following statement comes from a teacher that faced difficulties rns is interesting but in my case i often didnt receive any answers from my partner i wrote to plan meetings but he didnt answer most of the time sometimes he was available but i wasnt sometimes we faced logistics problems on one occasion there was a snowstorm so his school was closed on another occasion it was the end of semester for him and the beginning for me so we were not able to fit in a project for evaluation purposes students can learn with teammates from other schools thus enriching their social interactions for learning and knowledge building purposes table 2 shows such benefits for students from teachers perspective parents social representations of the rns the rns and regular classroom activities seven major themes emerged from our content analysis regarding what rns is about table 3 illustrates what was said types of representations of the rns concept parents discourse connect school communities maybe this will let children as i was saying have at least some possibility to communicate when you are two or three 11 th grade students well sometimes you would like to discuss the subject matter…i remember that when i was in school you had a problem with physics and you could discuss it with youre your friends at the school library when youre just the same group of fifteen people well its always fun to network when youre a teenager or even if youre child so you can create relationships even if you arent visually close you communicate with that person you see his or her face it still creates a relationship a communication no matter if its by correspondence by phone these are relationships that will remain for life… the feeling of not being all alone in your own little world even for teachers for teachers as well as for students it gives them the opportunity to make new friends not friends really…virtual friends and they can share experiences with them you know the fact that they are a group it lets them exchange all kinds of different ideas that come from all over connect teachers it could be useful too for teachers to communicate among themselves…maybe they could get some kind of training this way that also was excellent … instead of those teachers being isolated there is a marked improvement concerning subject matter by way of team teaching for him the rns is a means of making collaboration between teachers happen expansion of local community i think that air inuit and many other companies could use this videoconferencing that we are bringing here to the school hmmm this is a tool that we dont have and hmm im sure there are many companies that including air inuit that could use this new system if we could use this media here it would save a lot of time hmmm costs distance traveled accident risks and everything that comes with it the hospitals surely they dont have the same office as where i work i mean instead of traveling 1000 km to go to a meeting there about a conference that we could have with them over there its an experience a learning about differences and that adds up to a community that is not just closed in on itself opening on the world of children our children well they will grow from this experience and practically know how to use a computer hmmm with their eyes shut developing knowledge communities it permits the democratization of knowledge and interregional sharing of information table 3 parents representations of the rns concept a parent whose daughter has been part of the rns since 2nd grade made the following exemplary distinction i love it my daughter has almost no memories of a nonrns school i now know the rns through what my daughter is saying in our house instead of isolating teachers there is mutual improvement in the subjects with team teaching the rns is a good way to encourage collaboration among teachers the rns also shows that the schools of the region can survive with multigrade classrooms and some competition between teachers what i see so far in the rns is a more holistic approach one where the student can consider himself as a global citizen it is a revolution i now know the rns tools ivisit and kf the kf is interesting with its neural way of transmitting information it democratizes knowledge and its sharing across regions ivisit is more for distance learning and simultaneous classroom activities ivisit was designed as a tool for simultaneous distance learning between classrooms during regular classrooms activities the teacher is facing a class in a dominated dominating relationship the rns is a school with a broader vision one that allows for team teaching and diversity it allows for a greater range of possibilities than what is happening in ones town or region it offers possibilities to be a better global citizen in my daughters class they work 12 times per week cycle on ivisit and they work more often on the kf like in any other model there are parents who do not know what the rns is however the very fact that they had a consent form to sign regarding the research dimension of the rns assured that a minimum of information was brought into the home expectations toward the rns the main expectation of parents combines hope and skepticism and can be summed up by the following statement are we going to be able to do it some parents are aware that the rns is an important social innovation but they are wondering if all people involved in it will have the capacity to participate in it properly talking about whats going on in the classroom a parent with numerous expectations pointed to the diversification of pedagogical approaches his understanding was that it allows for more focus longterm concentration and motivation my daughter adores it it is very stimulating but she would not like to be in an rns all the time what she likes about it is the diversity of ways of learning the more diversity there is the more likely it is to have a better picture and be less surprised by the result when we meet someone who thinks differently other expectations were as follows the rns should allow students to acquire a larger background one that gets them closer to a knowledge community other classrooms in our region and city classrooms would then benefit from the way an rns operates yes the remote networked schools are important i hope they will allow certain schools to remain open otherwise they would be closed in relation to their local community the real impact of the rns is tomorrow it can energize a community for tomorrow change attitudes and foster an interest in icts it will have a longterm effect and it will expand the horizons of citizens who are currently students in spite of these expectations some parents interviewed during phase 1 mentioned an important concern about rns with this project and all these new resources are we going to lose a teacher this comment reflects the fear that teachers could be replaced by computers and the internet although this is not the intention of the rns design such comments were not mentioned by parents interviewed during phase 5 parents perceptions of their childs learning in a rns the primary skill children develop according to parents is the skill to work with icts the rns has provided some tools for exploration my daughter likes to go on the internet she uses technologies with interest she likes to use the videoconferencing tool and the forum she works with powerpoint and writes texts she sees how easy it is to transmit these another skill is openmindedness and capacity to accept difference she gained an awareness of the existence of difference this is an intellectual skill in the same way another parent stated the following it is great that they can communicate together they realize they are not alone in their small corner this increases their tolerance parents are not likely to know that the rns has improved their childs grades in a systematic way but one parent strongly asserted that the rns has helped her motivation he added there is no particular area but she likes everything connected to the rns regardless of the subject matter she verbalizes a lot about the presentations to do on ivisit or the act of composing a creative tale on kf its really positive she has a vision of the world she would not have had without ivisit some parents identified that rns helped their child develop communication skills she learned to talk better because of the videoconferencing system that requires her to express herself more clearly than in face to face communication shes able to talk to small groups of students all the while using precise words one last thing identified by some parents about childrens learning is development of social skills its all about the social aspect she has learned to work with people she didnt know before this requires being able to make concessions parental involvement participation in school activities rns activities to which parents contribute are the following ones presentations field trips schoolyard surveillance for instance some parents are invited to explain what they do in life in a few cases the videoconferencing system is used to give information access to other distant classrooms parents provide help to support teachers during special activities such as a snowshoe excursion or any other outside school activity that requires more supervision such surveillance is also provided during recess when students go to play in the schoolyard some parents are members of the parents committee and others respond when needed parents with a special expertise or interest in the educational system may bring data objects or documents that feed the learning projects there are parents who answer questions during an interview give comments and encourage new developments to build or improve educational systems parents role in the childs academic success in best cases there is a fixed amount of time for homework and a parent will answer hisher childs questions and offer support some parents offer more freedom and provide more flexibility than others they believe that their child must do what heshe loves and do not put too much emphasis on academic tasks another important aspect concerns giving encouragements to their child so heshe can feel heshe is supported other contributions some parents have bought computers for their child and see it as a plus at home its been three years since he has gotten a computer she plays making a powerpoint talking with friends on msn she uses technology as learning tools sometimes she accesses the kf from the house but this is rare of course there are parents who like in any other cases are not involved very few have refused to sign the consent form regarding the research dimension of the rns initiative above all parents have been curious of what the rns is and no resistance has been organized to counter its development and their childrens learning in the rns model some schools have been active in explaining to the parents the rns activities they held special meetings they had children showing their parents and local citizens how the rns tools work and what they do with them in other places parents would like to have more information about rns as they consider they dont know enough about it to really know what is all about we received some chunks of information about it at the beginning of the school year and sometimes during parents meetings but thats it discussion almost 10 years after its inception the rns initiative is more and more part of small rural schools in quebec and its appropriation by school districts is in sight teachers mainly recognize that it has contributed to the reduction of their feeling of isolation they see that this model is pedagogically effective with their students moreover the initiative has shown the sustainability of professional collaboration and the emergence of a collaborative culture although most parents do not participate actively in the rns activities they are aware of the model and agree to the gathering of data regarding their child who isare part of it this is in itself a manifestation of openness to change it could also be reflective of a democratic parenting style further inquiry will link rns parents representations to democratic parenting style found in scientific literature encouragement and direct involvement in the rns activities are valued by both teachers and school principals parents are often shy to offer their help because of the fear of being judged or not doing things the way educators expect moreover the very fact for a child of having the feeling that hisher parents support whats going on in school can have a positive impact on hisher relationship to school however it is striking how parents see the value of the rns in its social aspects rather than its academic one they are pleased that their child have more friends and the like deeper understanding is recognized by only very few parents nonetheless the fact that no parent interviewed in phase 5 shared a worry about seeing teachers being replaced by icts in comparison to what they expressed during phase 1 is found positive this suggests a rather successful degree of implementation of the model in schools and school boards that have adopted it parents who are the most knowledgeable about the rns see it as a growth opportunity for children to become world citizens however most parents still do not connect the rns with the development of their community more direct interventions towards them could be a path of development that could insure that the rns not only be an efficient model to enrich students learning environment but also a true way to insure communities vitalization and emancipation it is certainly a good sign for small villages needing revitalization that these parents are open to change the rns model has confronted their thinking regarding what school is all about and they are rising up to the challenge facing both their academic institutions and their communities

the importance of peer interaction for learning purposes is a wellknown fact in educational theory and a school of a small size is particularly challenged to engage sameage students in social exchange of this nature for almost a decade an action research partnership laferrière breuleux 2002 has been established a systemic approach was applied banathy 1991engeström 1999seidel perez 1994 it has meant tackling an educational challenge and social one as well as distance from urban areas using the support of the internet partners objective was to design and study see design experiment methodology brown 1992collins 1992 1999 from an ecological perspective nardi oday 1999 the model that was cocreated was meant to enrich interactions for learning purposes in rural schools more concretely with the use of information and communication technologies icts we designed a model whose purpose is to bring classrooms of different schools and regions to work and learn together this paper focuses on two poles of results of the remote networked school rns model 1 the advantages of collaboration between schools from teachers point of view 2 parents social representations of the rns model and its value as it pertains to their childrens education

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introduction child maltreatment is an illegal and unethical practice based on neglect physicalsexual abuse illtreatment and economical exploitation of individuals 18 years of age 1 the serious adversities of maltreatment impact the physical and mental health of children for a longer duration the affected children experience a significant reduction in their healthrelated quality of life and qualityadjusted life years in addition the absence of family and community support worsens their symptoms and adds to their disabilityadjusted life years maltreatment impacts the dignity of the affected children and reduces their sense of responsibility towards their families community and the broader society 2 it also deteriorates their interpersonal relationships with peers and family members the incidences of child maltreatment are reported in schools homes workplaces and in the open environment communitybased exploitation adds to the misery of children and increases their predisposition to physical disabilities and mental health conditions with the advent of the internet harassment of children in the virtual world deteriorates their personalities and disrupts their normal physiological development the united nations childrens fund has recently recognized child maltreatment as a public health concern requiring the immediate attention of the global community 3 4 5 importantly the united nations high commissioner for human rights office advocates the need to implement administrative and legal interventions across the globe to minimize the rising incidence of child maltreatment 6 nations in the middle east lack the provision of robust and systematic measures to record and analyze the cases of child misconduct and their healthrelated social implications the underreporting of child maltreatment hinders the statistical analysis of its incidence and prevalence across the middle east 7 the complexities concerning child maltreatment and its deep roots in cultural norms and middle east traditions are the biggest challenges requiring the intervention of the community social care organizations and federal agencies findings from the latest studies indicate the episodes of psychological misconduct and physical harassment of children in the middle east in a ratio of 34 however these ratios in female children are 14 and 15in male children respectively 8 the harmful and pervasive conventions and social practices trigger episodes of severe violence in children of the mena 49 the children who migrate between different middle east locations for refuge often experience violence during their travel evidence reveals the rising incidence of child trafficking and the utilization of children in smuggling activities across mena 10 methodology the current review included the literature published up to the present date and the literature search was done using the following electronic databases such as pubmedmedline web of science scopus embase google scholar cinahl and proquest the search strings used in the study child or adolescent or teen or youth or schoolaged or young people or children or preschool and maltreatment or physical abuse or psychological abuse or emotional abuse or child maltreatment or child neglect the first level of keywords includes prevalence point prevalence incidence and crosssectional studies longitudinal studies and observational studies the second level of keywords includes risk factors predictors correlates association and prevention the determinants include demographics such as age gender parents education status parents income social status and parents psychological well being result child maltreatment prevalence in the middle east and across the globe data from child protection agencies reveals episodes of violence in ≥66 million children attributing to 36 million referrals towards safe locations in addition ≥5 deaths per day are the outcomes of child abusemaltreatment across the globe 11 recent studies reveal 8288 incidence of domestic violence in the middle east 12 in addition 0046 billion children in mena experience episodes of violence and misconduct leading to an 88 incidence of maltreatment 12 moreover evidence correlates child maltreatment cases in syria with the rising incidence of child marriages 13 the episodes of abuse and misconduct are the outcomes of longterm conflicts between caretakers and their urge to exploit children under the pretext of their cultural requirements continuous migrations and displacements further increase these episodes and adds to the misery of vulnerable children recent findings of unicef reveal 77 incidence of childadolescent mistreatment during the migration of their families via the central mediterranean region 12 people from the subsaharan nations reportedly victimize and abduct children to satisfy their illegitimate businesses a recent analysis of the indian population indicated an 899 incidence of child mistreatment 14 the subgroup analysis revealed a 199 incidence of lifetime episodes and a 167 incidence of sexual misconduct in the affected children 14 table 1 depicts the overall maltreatment prevalence classified into physical emotionalpsychological sexual and neglectrelated events in middle east nations the findings from a recent crosssectional study indicated a 1065 incidence of child maltreatment in saudi arabia including the highest prevalence of psychological misconduct and the lowest of sexual abuse 15 the evidence further reveals 683 incidence of ≥1 maltreatment episode among most female children in jeddah saudi arabia 16 however another study from saudi arabia reveal a 29 incidence of sexual abuse 451 of physical abuse and 506 of emotional misconduct in female children 17 also a recent study in kuwait reveals ≥1 episode of sexual emotional and physical abuse in 198 535 and 356 of firstyear university students respectively 18 importantly 709 of these students were females 18 similarly outcomes from another study confirm ≥1 incidence of aggression in 30 of children in lebanon 19 the findings also indicated ≥1 episode of physical misconduct and ≥1 psychological abuse event in 54 and 65 of children respectively 19 another retrospective analysis reveals a 39 mortality rate in maltreated children in egypt 20 findings indicated the involvement of fathers and male female perpetrators in the violence episodes against the targeted children in addition 732 of female perpetrators were mothers of the affected children the study findings also classified perpetrators into separated couples individuals with low education highly educated people illiterates and rural residents 20 perpetrator is a person engaged in episodes of child misconduct or maltreatment 21 a large cohort study emphasized the causes of the rising incidence of child maltreatment the findings indicated the engagement of one or both parents relativesfriends neighborsdaycare providers fathers and mothers in child maltreatment episodes 22 additionally evidence indicates the limited implementation of tertiary or secondary prevention approaches due to the gross underreporting of child maltreatment cases in the middle east 23 in addition the ongoing abuse against children increases the risk of developmental degradation and reduces their mental health outcomes a vast majority of these children imitate and practice violencemisconduct in the later stages of their life eventually child maltreatment progresses without interruption across generations in the absence of viable measures therefore the formulation of evidencebased strategies against child maltreatment is paramount to preventing this societal problem in the current and future generations 24 child maltreatment risks and protective factors risk factors the predisposition of children to maltreatment varies with societal communitybased interpersonal and individualized factors factors including health care requirements gender and age significantly influence the incidence rates of child maltreatment across the middle east 25 children 5 years of age experience the highest risk for abuse and misconduct in middle east countries 232627 however findings of the national child abuse and neglect data system indicate a high prevalence of maltreatment in children in the united states 28 also data suggest that male children are more vulnerable to abuse and maltreatment compared to female children 2429 in addition physical abuse with male children is a widely reported event across oman and saudi arabia 2326 however the prevalence of sexual misconduct with children has the highest prevalence in jordan and yemen 2730 disabilities in children further elevate their maltreatment predisposition in the middle east other risk factors include attention deficit hyperactivity disorder behavioral complications and chronic diseases 2430 maltreatment exposure is reportedly high in children with consistent dependency on caretakers importantly the education level of children and their families potentially influences their maltreatment risks and outcomes several studies have correlated low levels of literacy in underprivileged households with higher episodes of child maltreatment 2630 the education levels of most underprivileged children in the middle east are below high school these children experience a high incidence of maltreatment compared to the privileged children residing with educated parents data reveal the adverse impact of womens empowerment on the episodes of child maltreatment in the middle east nations of the gulf cooperation council 31 the employability of women in these nations disrupts their worklife balance which eventually adds to the risk of maltreatment in their children the increased dependence of such children on housekeepers and external support also exposes them to maltreatment in the absence of their mothers importantly lowincome nations report the highest incidence of infant homicide in the middle east 32 large households with limited living space also add to the risk and incidence of child maltreatment 33 additionally frequent changes in family structures increase the interactions of children with newly added members or distant relatives thereby increasing their risk of maltreatment 34 the risk of child abuse increases further in households with disturbed infantmother relationships arising due to perinatal complications 35 mentally ill mothers often mistreat their children under the impact of their depressive episodes stress or frustrations they often fail to satisfy the caretaking requirements of their children while attempting to achieve their career ambitions 3637 the provision of stepparents and the prevalence of substance abuse and alcoholism in children predisposes them to abuse and misconduct 3839 the psychosocial complications of caretakers parents further increase the incidence of misconduct with their children marital disharmony and job dissatisfaction among parents add to the episodes of violence and aggression against their children 37 additionally the social issues across urban locations further impact the mental health and wellness of parents 40 the respective children consequently experience a high exposure and incidence of violence and abuse the greatest factors hindering the implementation of child maltreatment prevention measures in the middle east correlate with the social fabric traditions and faithbased norms 41 parents refrain from reflecting on their shortcomings and vehemently oppose the liberation of their children they also adhere to authoritative parenting approaches and refrain to adopt prosocial behavior these sociocultural obstructions in extended families add to the vulnerability of children and increase their encounters with traumatic episodes 42 importantly child abuse practices in the middle east are cascaded across generations based on ongoing traditions supporting the need for corporal punishment and moral policing 3643 the upbringing of children with these inhuman practices normalizes the episodes of misconduct in their daily routines protective factors the factors that effectively reduce the risk and prevalence of child maltreatment in the middle east include the selfesteem adaptive functioning social competence and selfregulation skills of both children and their parentscaretakers 363744 in addition the social support system of parents reduces their engagement in child maltreatment practices mutual understanding between parents and their positive interpersonal relationships lowers the incidence of their conflicts intimate partner violence and child abuse supportive marital relations between individuals with a history of child maltreatment improve their mental health and reduce the risk of their engagement in violent activities 4245 importantly community support effectively minimizes misconduct and restricts the occurrence of antisocial practices social bonding between individuals at the community level improves their overall conduct and selfcontrol parents eventually develop an empathetic attitude towards their children and cater to their wellness requirements 46 such modifiable structural characteristics and social processes have the potential to provide a supportive environment that encourages positive parenting 47 social networking between people helps them intervene in the episodes of child maltreatment and act as whistleblowers against unethical practices other important protective factors include the provision of parental education healthcare facilities and a positive environment at home 48 importantly the availability of mental health care services reduces the frequency of child neglect and traumatic experiences an effective legal system conducive to the wellbeing of children encourages them to selfreport maltreatment episodes to the designated authorities regular wellness trainings for atrisk children increase their selfawareness and help them recognize the signals of misconduct in their community environments 49 the provision of awareness campaigns by social workers health care teams and teachers improves child advocacy practices and safeguards the rights and privileges of vulnerable children furthermore the participation of people in child maltreatment prevention training symposiums and conferences improves their selfmanagement skills and resilience these support systemstraining also prove to be the greatest facilitators of child protection measures and help individuals to challenge the unethical societal norms customs and traditions against authoritative parenting media outlets also play a leading role in developing the perspectives and beliefs of people against child maltreatment 50 regular dissemination of child prevention guidelines via newspaper articles youtube videos television programs podcasts and radio broadcasts help modify the community environment and prepare individuals to combat misconduct and violence against children other important measures against child maltreatment include the provision of fundraising events exhibitions discussion forums communitybased programs and websites targeting the prevention of child maltreatment incidences in the middle east regions 5152 the impact and outcomes of child maltreatment findings in the contemporary literature emphasize the longterm impact of maltreatment on the physiological behavioral emotional and social development of the affected children 2653 physical abuse and misconduct add to the incidence of disabilities that adversely impact their health wellness and quality of life some of the prominent disabilities include brain damage walking difficulty and memoryvisionhearing loss 54 the traumatic episodes in children can result in wounds fractures burns and bruises that adversely affect the daytoday functioning of vulnerable children in addition children with fatallifethreatening injuries experience a high risk of death 55 child maltreatment reduces the qualityadjusted life years and increases the disabilityadjusted life years of the exploited children they experience a high risk of developing altered consciousness states dissociative identity disorder anxiety and depression 265657 in addition their low selfesteem reduces their coping skills and adds to their risk of several mental health conditions children with maltreatment exposure tend to lose focus and develop hyperactivity attention issues and learning disorders 58 they also experience cognitive decline and their low emotional intelligence adds to their risk of mental health complications they face substantial challenges in developing peer relationships and experience high difficulties in maintaining social contacts 59 children with a history of maltreatment imitate similar misconduct with peers and often engage in abusive relationships they tend to continue and contribute to the vicious cycle of aggression violence and misconduct during adulthood 60 these findings indicate serious and longterm implications of child misconduct in human societies physical outcomes the physical injuries from maltreatment adversely impact the wellness paradigm of the affected children 61 physical abuse increases the risk and incidence of several clinical complications including subdural hemorrhage brain trauma burns and bruises in the pediatric population 23 62 63 64 the complications from shaken baby syndromeabusive head trauma skeletal injuries sexual abuse and neglect often lead to growth failure dental caries malnutrition scapularspinalsternal fractures and hematuria these clinical complications adversely impact the academic performance and overall personality development of the affected children sexual abuse in children often results in anal genital trauma that increases the risk of unwanted pregnancies and sexually transmitted diseases 65 neglect or lack of parental supervision followed by misconduct increases the incidence of poisoningtoxicities infections unattended diseases obesity and vitamin deficiencies 6667 lack of nutrition not only leads to malnutrition but also challenges the physical development of the affected children leading to the development of failure to thrive indeed child maltreatment increases the predisposition of abused children to obesity in their later phases of life 6869 also physical misconduct and violence against children result in brain dysfunction deafness complete blindness and death high mortality rates were reported in children of age 5 years following the episodes of their maltreatment including neglect and abuse 70 evidence indicates the implications of child maltreatment history in individuals of age 41 years 71 the racesexgenderadjusted findings reveal the occurrences of respiratory complications visual field defects kidney damage liver dysfunction and poor glycemic control in adultsmiddleaged individuals with past exposure to misconduct during their childhood data further reveal incidences of oral health complications and hepatitis c in adults after 30 years of childhood maltreatment including sexual abuse 71 the profound longterm impact of maltreatment on the health outcomes of children during their adulthood is evidenced by several studies after adjusting other possible causes including mental illnesses smoking history sedentary lifestyle socioeconomic crises and demographic factors 71 cognitive outcomes evidence indicates the passive impact of maltreatment episodes on the academic performances and executive functions of the targeted children neglect and abuse of children deteriorate their communication and language skills and increase the risk of neurocognitive disorders 7273 many children with a history of maltreatment experience substantial delays in their intellectual development marked reductions in their verbal intelligence challenge their expressions and predispose them to longterm mental health complications 72 importantly they also experience trouble in coping with panic circumstances and face difficulty in solving complex problems 7475 the impact of maltreatment on the academic performances of children is evidenced by their high special education needsreferrals failed grades low test scores and unsatisfactory conductresponsiveness in classrooms 76 77 78 79 importantly children with a history of abuse have reduced focus memory issues and low verbal intelligenceepisodic memory 80 psychological complications children with maltreatment experience a high risk of psychosocial complications not only during childhood but also at later life stages findings from several studies reveal a multifold risk of lifetime depression in children affected by violenceaggression and neglect 2781 maltreated children with depression show low responsiveness to standard treatments and have a high risk of subsequent abuse and recurrent depression 82 a high incidence of posttraumatic stress disorder is observed in children with a maltreatment history children with ptsd experience mood alterations hyperarousal avoidance and intrusive thoughts that adversely impact their wellbeing and quality of life in addition they experience a high risk of depression anxiety and panic attacks 83 84 85 data suggest a fourtimes greater risk of personality disorders in maltreated children compared to those without a mistreatment history 8687 evidence also reveals a high prevalence of borderline personality disorder in children with a history of abuseneglect compared to those with psychosocial complications 88 in addition child maltreatment increases the risk of drug dependence and alcoholism during adulthood 89 most children with substance abuse including drug addiction and alcoholism reportedly have a history of maltreatment compared to otherwise healthy children 9091 these findings indicate psychological complications as the independent predictors of child maltreatment in the middle east and across the globe behavioral and social outcomes neglect and maternal detachment predominantly deteriorate the emotional bonding of children with their parents which eventually impacts their emotional intelligence and social networking skills 92 the vulnerable children experience substantial difficulties in expressing their concerns and expectations in front of their parents maltreated children with emotional dysregulation also have difficult relationships with their peers and low coping skills 93 other outcomes of maltreatment in children include aggressive conductviolent behavior engagement in crimes delinquency promiscuity truancy the tendency to escape and conduct disorders 94 95 96 97 moreover tendency to commit physical assaults and social withdrawal are significant attributes of children with a history of neglect and abuse 98 99 100 importantly child maltreatment also increases the risk of recurrent abuse and violence among its victims their offensivedisrespectful behaviors and abusive relationships in later life stages fuel the vicious cycle of child maltreatment and cascade it to subsequent generations 101 102 103 child maltreatment prevention the prevention and mitigation of child maltreatment practices is the key to discouraging other malpractices including intimate partner violence and genderbased inequalities in the middle east 104 105 106 evidence indicates a marked reduction in adolescent arrest and delinquency incidences following the implementation of child maltreatment prevention programs including home visits 107108 the child abuse prevention measures in different regions reciprocate with their cultural conventions and communitybased norms and practices 109 since economically weaker sections of middle east society experience a high risk of child abuse financial assistance to underprivileged families is the key to reducing child maltreatment episodes 110111 economic support to underprivileged societies assists in fulfilling their unmet needs and reducing the risk of depressionanxiety in parents 112 furthermore subsidies to lowincome groups assist in accomplishing their nutritional demands these measures eventually increase the overall quality of life of underprivileged families and lower the risk of mental illnesses and associated child abuse episodes other prevention approaches include the implementation of safe workplace policies and the provision of sickpaternity leaves for the workforce 113 positive parenting and parental support are the key measures to minimizing the incidence of child maltreatment and abuse in the community environment 114 the provision of training and support via communityhomebased sessions assists in improving the parenting skills of caretakers 115 psychosocial support including cognitive behavior therapy is another potential measure to change the attitudes behaviors and conduct of parents against child abuse 116 child maltreatment prevention campaigns through media outlets also help to transform the thinking processes in people and reduce their apprehension about parenting challenges 115117 importantly the implementation of the 2030 agenda for sustainable development by the united nations is necessary to prevent discriminatory practices against children and to protect their dignity and human rights 118119 childhood care in foster homes and native residences increases the sense of safety among children and improves their societal perceptions it also strengthens their interpersonal relationships with caretakers relatives and peers 120 educational sessions at the preschool level in association with guardiansparents improve the executive functions of children which eventually enhances their academic performances findings from a recent study reveal noticeable reductions in child maltreatmentrelated petitions following the enrolment of parents in child abuse prevention programs 121 evidence confirms the role of parental support programs based on early childhood home visiting in improving parenting skills and minimizing the incidence of child mistreatment 122 a 50 decline in crimes against children and maltreatment episodes were observed following the implementation of the nursefamily partnership program 123 the safecare and incredible years programs also aim to improve parenting skills for reducing the prevalence of child maltreatment episodes 124125 these programs also aim to foster primary care of parents and develop holistic strategies to effectively mitigate child maltreatment risk factors 126 studies demonstrate the role of cognitive behavioral therapy in reducing abnormal behaviors and minimizing traumarelated psychosocial complications in children 127 the evidence further indicates the role of childfriendly helplines to increase the early escalation of mistreatment events 127 crossprofessional collaboration between public health personnel administrative personnel children parentscaretakers social care organizations and federal agencies is necessary to challenge the rising cases of child maltreatment in the middle east regions 128 it is important to note that despite the child protection legislation in mena crimes against children continue to increase due to financial crises infrastructure challenges and limited public funding armed conflicts in the middle east nations add to the risk of wars and create an environment of fear and financial instability which further increases the risk and incidence of childhood trauma 129 accordingly middle east countries need to collaborate and formulate comprehensive measures to extend psychosocial and financial support to underprivileged families in order to minimize the rising incidence of child maltreatment 31130 conclusion the high incidence rates of child maltreatment in the middle east warrant proactive measures from the governmental authorities and social care organizations to improve parenting skills provide extra privileges to the stratified societies and administer awareness campaigns it is important to strengthen protective factors and implement preventive approaches to reduce the risks of maltreatment in underprivileged children future studies should compare child maltreatment incidences and outcomes in the middle east with other nations of the globe to standardize prevention approaches conducive to the reduction of child abuse cases and their deleterious complications 131 132 133 134 135 136 137 138 139 140 141 142 conflict of interest the authors disclosed no conflict of interest

child maltreatment is the most prevalent and underreported issue in the middle east and across the globe misconduct with children has adverse effects on their overall health wellbeing and psychosocial development for the longer term this review aimed to investigate recent evidence concerning child maltreatment prevalence risks protective factors and outcomes in the middle east it also evaluated warranted prevention strategies to combat the rising cases of child maltreatment and minimize its serious adversities sixtyfive primary and secondary studies were included in this study after rigorous screening through pubmedmedline web of science scopus embase google scholar cinahl and proquest evidence revealed an 88 incidence of child maltreatment in the middle east factors including economic crises lack of education and substance abuse add to the maltreatment exposure of vulnerable children findings indicated the adverse impact of maltreatment on the overall mental and physical health and social development of the affected children the protective factors include community support selfregulation child prevention awareness campaigns and training social competence and high selfesteem in conclusion findings from this review emphasized the need to address child maltreatment in the middle east and formulate viable approaches to improve parenting skills satisfy the nutritionalfinancial requirements of underprivileged families and improve interpersonal relationships of children with their caretakers

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introduction energy poverty affects numerous households across the globe and has several key implications and concerns for public health and social equity energy poverty is defined as the lack of access to modern and affordable energy services 1 individuals or communities in energy poverty face limitations in accessing reliable affordable and sustainable energy energy poverty has traditionally focused on the global south because the vast majority of people who have no access to electricity live in the poorest regions of the world asia and subsaharan africa 1 however previous research has uncovered the significance of energy poverty for developed world countries in the global north 2 in the us african american latinx and multifamily renters disproportionately endure energy burdens 3 for instance lowincome households in us cities spend nearly three times more on energy costs than nonlowincome households according to 2 14 of the us households nearly 17 million families received an energy disconnect notice and energy bills that undermined the ability of 21 of households to buy medicine and food the response to energy poverty in the global north countries varies significantly for instance the uk has recognized energy poverty as a distinct issue and implemented integrated and effective policies to address energy poverty through climate and social justice initiatives 2 in the united states several initiatives and programs have been implemented to address energy poverty and improve access to affordable and reliable energy such as lowincome home energy assistance program and the weatherization assistance program liheap is a federal program that provides financial assistance to lowincome households to help them meet their energy needs it offers grants to assist with heating and cooling expenses energy crisis intervention and weatherization services to improve the energy efficiency of their housing units wap is a federal program that helps lowincome households reduce their energy consumption and lower energy costs by providing free home weatherization services these services include insulation air sealing and energy efficient upgrades to heating and cooling systems liheap performance measures program promotes energy conservation and efficiency among liheap recipients by encouraging practices that reduce energy consumption and enhance energy efficiency in lowincome households energy efficiency and conservation block grant program provides grants to state local and tribal governments to fund energy efficiency projects and initiatives these projects aim to reduce energy consumption improve energy efficiency and decrease energy costs for lowincome communities community action agencies are local organizations that administer various programs aimed at addressing poverty including energy assistance programs these agencies help lowincome households with energy bill payment assistance energy efficiency education and weatherization services the us has also focused on promoting renewable energy initiatives to address energy poverty and reduce greenhouse gas emissions federal and statelevel policies encourage the adoption of renewable energy sources these initiatives aim to increase energy affordability resilience and sustainability utility assistance programs offered by many utility companies support lowincome customers in meeting their energy needs furthermore with the passage of the bipartisan infrastructure act and the inflation reduction act new credits incentivizing clean energy technology adoption have been introduced an addition to these credits new guidance led by the justice 40 initiative aims to ensure that 40 percent of the overall benefits of certain federal investments flow to disadvantaged communities that are marginalized underserved and overburdened by pollution despite the progress of the previously mentioned programs and initiatives implemented by the us federal government the scope of the assistance of these programs is insufficient to address the energy burdens of all vulnerable families 2 as a result after five decades of federal energy assistance onethird of households in the us experience forms of energy poverty according to 2 one primary gap is the lack of recognition of energy poverty as a national challenge that requires careful definition goals and policy evaluation the continuing prevalence of energy poverty globally and the new us initiatives aimed to help alleviate it make this an ideal time to examine the literature related to energy poverty if we do not learn from previous experience then the efficacy of the incoming programs could be diminished therefore the purpose of this paper is twofold to help categorize and describe recent and key energy poverty research identified by the nsf 2026 priorities and research needs for an equitable energy transition workshop and the united states department of energys office of energy justice policy and analysis and identify how the main findings from these works should be applied to our new incentive heavy current environment or how their work should be expanded to address pressing issues we have chosen the nsf 2026 priorities and research needs for an equitable energy transition workshop 4 and the united states department of energys office of energy justice policy and analysis 5 to center this work around because the workshop included top researchers who widely disseminate their work globally and because of the importance of energy justice in policymaking at the department of energy that created a new office to look at how policy should take energy justice into account and the work highlighted by this office will directly affect policy the workshop hosted faculty from 11 prominent colleges and universities to identify research priorities at the intersection of energy technology and social justice which led to the publication of a comment publication 6 this work expands on these two sources by investigating the themes behind the literature that was highlighted discussed and recommended by these groups as a whole and by the people within these groups thus understanding the works highlighted by these two sources will inform the reader of the work done by leading practitioners in the field and the work that is being used to directly influence us energy policy we believe the limited scope of this paper aids in readability and in focus as it presents readers with a novel perspective that allows them to glean new insights quickly and explore the rest of the vast energy poverty as needed this review paper uses five themes as shown in figure 1 to organize the previous energy poverty work the rest of the paper is organized as follows section 2 will provide a general background on energy poverty and energy justice sections 37 will describe the main idea behind one of the five themes present a table of relevant papers within that theme including the methods and the ideas behind the results and summarize how the research in that theme can be used or how it should be expanded section 8 will discuss our main findings finally section 9 will provide the main conclusions from this review and provide directions for future work background on energy poverty and energy justice energy poverty refers to instances where households lack sufficient access to affordable and reliable energy services thereby hindering their ability to meet basic needs and maintain a decent standard of living 7 this condition disproportionately affects vulnerable and marginalized populations including lowincome families elderly individuals and those living in substandard housing 2 a critical aspect of energy poverty lies in its connection to social inequality where vulnerable communities face heightened exposure to its adverse effects this not only perpetuates disparities but also has the potential to create energy underclasses 7 moreover energy poverty poses significant risks to human wellbeing particularly concerning inadequate access to heating and cooling leading to health issues and reduced thermal comfort 8 energy poverty is a pressing global issue that has gained growing concern for the uneven energy access and consumption among wealthy and lowincome communities that expose impoverished families to energy poverty issues 9 although global north cities like those in the us have relatively secure energy infrastructures and resources lowincome households and ethnic minorities often face challenges accessing affordable and clean energy services 10 the implications of energy poverty are farreaching impacting human wellbeing social inequality housing conditions and the environment 211 as a result addressing energy poverty requires targeted policies prioritizing social welfare and energy efficiency to promote equitable access to energy resources and support sustainable energy solutions however energy poverty is a complex issue that requires a comprehensive assessment of accessibility affordability and quality of energy services for households and individuals energy poverty is a condition where a household lacks access to adequate reliable and affordable energy services such as electricity and fuels for cooking and water heating several factors influence the nature and extent of energy poverty including household income the quality and characteristics of housing units and technological innovations and energy costs energy poverty is often measured as a percentage of household income spent on energy costs the us department of health and human services considers energy costs above 6 per household income a high energy burden however many lowincome households spend more than 10 of their income on energy bills with some spending as much as 2050 geographical variations like climate energy costs and home energyefficiency also affect energy poverty households in colder climates may have high heating bills while warmer climates may have high cooling costs rural areas often face higher energy burdens due to increased transportation and energy infrastructure costs this reveals the significance of the spatial location of housing within metropolitan areas that influences the extent to which residents commute to job locations rural and periurban residents with low incomes may commute longer than their urban counterparts and often lack easy access to transit or private vehicles increasing both transportation and energy burdens 3 energy justice is a comprehensive and evolving concept 9 that includes an integrated approach to understanding and addressing the disparities and injustices in the global energy system 1213 energy justice draws from the principles of environmental justice including distributional justice recognitionbased justice and procedural justice 1214 these principles provide a framework for identifying and addressing energyrelated injustices emphasizing equitable allocation of energyrelated benefits and burdens recognizing marginalized groups and including affected communities in decisionmaking processes 131516 the concept of energy justice encompasses complex issues such as excessive consumption of energy which triggers greenhouse gas emissions and air pollution as well as the inability of lowincome families to afford or access to necessary energy and fuels resulting in energy poverty underconsumption and health burdens 10 energy justice seeks to mitigate energy poverty by supporting improved electricity access sustainable energy use practices poverty reduction and enhanced wellbeing for all individuals regardless of income race and ethnicity 9 by integrating ethical considerations into energy policy and decisionmaking energy justice is a guiding principle for a more just and inclusive energy system that fosters social equity and environmental sustainability 13 the research further follows the development of renewable energy and technological innovations drawing from the principles of energy justice to address energy poverty strengthen local economies by creating jobs increase local tax revenues and decrease energy costs in most cases communities needing economic growth and job opportunities cannot implement renewable energy to its full potential there are several locations where such disadvantaged communities have a high potential for costeffective renewable energy generation and its implementation could spur economic growth and job creation energy poverty and justice definitions and metrics metrics used to assess energy poverty encompass various indicators and methods aimed at quantifying its extent and impact on different societal levels one such metric involves evaluating the percentage of household income spent on energy bills commonly referred to as energy burden 17 additionally researchers have used data on energy disconnect notices and instances of households forgoing essential needs like food and medicine to pay energy bills to identify and measure energy insecurity or energy poverty 18 table 1 lists a select set of papers that either develop new metrics or use a combination of metrics to measure energy poverty it summarizes research approaches to examine energy poverty energy consumption patterns and the influence of demographic and socioeconomic factors on energyrelated behaviors these studies may inform energy policies and programs to alleviate energy poverty and promote sustainability furthermore these studies highlight the importance of comprehensive studies that include integrated metrics and socioeconomic factors because a single metric or measure cannot understand the complexity of energy poverty and the implications of policy impacts over time the energy equity gap reveals a hidden aspect of energy poverty that is complementary to energy burden showing that more than one metric is needed nock et al 2020 20 changing the policy paradigm a benefit maximization approach to electricity planning in developing countries formulated the expansion planning problem as a utilitymaximization mixedinteger linear program case study focused on a lowincome country with limited electricity infrastructure investigated investments that take consider stakeholder equity preferences using a maximize energy access model considering equity metrics in planning resulted in a more interconnected grid with more transmission and decentralized energy sources and less centralized power bednar et al 2017 21 the intersection of energy and justice modeling the spatial racialethnic and socioeconomic patterns of urban residential heating consumption and efficiency in detroit michigan used gis bottomup modelling smallarea estimation techniques calculated energy consumption and energy use intensity using metrics such as age of housing income demographics expenditures and more revealed the importance of focusing on a comprehensive assessment of energy use rather than just consumption a thorough energy assessment including socioeconomic factors may identify vulnerable households and effectively target energy efficiency programs previous research summarized in table 1 used several energy poverty metrics that may help conduct a comprehensive assessment these metrics include energy consumption household income housing age and quality socioeconomic information including race and ethnicity energy behavior access to energyefficiency programs promoted by the federal government household with alternative energy sources access to technological innovations to mitigate energy use and emissions furthermore one of the most important recent innovations in the energy poverty metric space was the creation of the energy equity gap energy equity refers to fair distribution of benefits and burdens of energy production and consumption an energy equity gap can occur when certain groups often lowerincome households face disproportionate energy burdens 19 these households typically spend a larger proportion of their income on energy costs than their wealthier counterparts this is an issue of concern as it is a contributor to and a result of wider social and economic inequality lowincome households may live in less energy inefficient homes due to a lack of resources or options leading to higher energy bills 3 they may lack access to affordable clean energy sources and efficiency programs meaning they spend more on fossil fuelbased energy and face associated health risks ref 20 examined how generation and transmission planning that takes into account equity preferences could help alleviate these concerns albeit at a higher cost but in order to use equity to help make decisions you must be able to quantify it and one tool to do so is the maximize energy access model finally ref 21 shows that energy metrics like energy use intensity can also highlight discrepancies in energy services even when energy burden does not ref 21 illustrated the phenomenon mentioned in 19 namely that wealthier households can more easily afford energy efficient appliances or renewable energy technologies like solar panels which can lower their energy bills and contribute to a cleaner environment energy poverty whether that is measured by is closely tied to a variety of issues including housing policy social policy and climate policy efforts to address this gap can include measures like targeted energy efficiency programs subsidies for clean energy technologies for lowincome households improved regulations and standards for rental properties and initiatives to increase the energy literacy of consumers the lowincome households tend to spend a higher proportion of their income on energy primarily due to less energy efficient housing and limited access to clean affordable energy sources addressing this gap requires a multifaceted approach integrating housing social and climate policies with a focus on energy efficiency affordability and clean energy access for lowincome households policies that take into account multiple metrics beyond energy poverty can do a better job of achieving energy justice further research is needed at more granular levels so that utilities can have tools for their region and to further distinguish the different forms of energy poverty behavioral aspects of energy poverty energy behavior refers to the actions and habits of individuals or groups related to energy consumption and conservation it includes a wide range of behaviors including daily practices such as turning off lights when not in use to more significant and costly decisions like choosing energy efficient appliances installing renewable energy systems or opting for electric or hybrid vehicles over those powered by fossil fuels numerous factors including socioeconomic factors personal attitudes beliefs about the environment cultural norms and energy policies influence energy behaviors individuals more aware of the implications of energy use for the environment are often more likely to engage in energysaving behaviors this reveals the importance of environmental education for energy behavior similarly financial incentives or policies promoting energy efficiency can encourage individuals especially lowincome households that struggle to afford technological innovations to use and benefit from energy efficient appliances or renewable energy systems energyrelated behaviors significantly affect energy use greenhouse gas emissions and sustainable development by understanding these behaviors policymakers and researchers can develop strategies to promote energy conservation and the transition to clean energy sources table 2 lists a select set of papers that either investigate how household behavior affects the efficacy of certain programs and how it affects energy poverty overall surveyed cbos questions such as how do cbo leaders identify sustainable communities how essential are each of the three sustainability pillars to their purpose these results illustrated how different terms and missions affected how cbos understood and behaved to achieve their version of sustainable communities for some energy poverty was essential but for others it did not matter at all the results show that households can limit the energy they would otherwise use to save money this energy limiting behavior affects energy equity the articles in table 2 show that how stakeholders define topics related to energy poverty is a key indicator to how they will act on energy poverty even for benevolent organizations like cbos 22 shows that their desired impact on energy poverty can be negligible as a result 23 created a social life cycle assessment framework that helps decision makers understand how different stakeholders would act under different scenarios lastly the work of 19 already highlighted in the energy metric section shows how households do respond to energy burden by limiting their energy use therefore behavioral aspects of energy poverty and conservation should be converted into quantifiable metrics to delineate informed decisions a comprehensive understanding of the energy behavior of lowincome populations who tend to use little energy but endure poor living conditions can help address energy poverty challenges more effectively the research directly relating energy behavior to investment or operational decisions is limited and should be expanded furthermore policymakers must consider stakeholders will respond to their policies and if that will affect its efficacy efficacy of energy assistance programs efficacy of energy assistance programs in the context of the united states refers to the effectiveness of various initiatives aimed at promoting energy conservation and increasing the use of energy efficient technologies these programs include financial incentives such as rebates or tax credits for installing energy efficient appliances or renewable energy systems educational campaigns to promote energy saving behaviors and regulations requiring increased energy efficiency in buildings and vehicles the efficacy of these programs is typically measured by the amount of energy saved or the reduction in greenhouse gas emissions achieved relative to the programs cost this can include direct savings from reduced energy consumption as well as indirect benefits such as improved public health from reduced air pollution table 3 lists a select set of papers that investigate the efficacy of selected energy assistance programs the table includes the title and authors of a paper a short description of the methods used and a short summary of the results measured metrics such as costeffective energy savings health and safety benefits job creation reliability number of retrofits the absence of a formal recognition of energy poverty constrains the efficient application of aid instead most aid is delivered based on metrics like income which constrains the ability to address energy poverty and its root causes directly past studies reveal the importance of energy justice and equity in energy policy interventions and provide valuable insights to optimize the effectiveness of energy assistance programs in addressing energy poverty and promoting sustainability as concurred by 22425 government energy efficiency programs can create schemes to reduce the energy burden on lowincome households however ensuring that government funding actually reaches the targeted beneficiaries is also essential because some of the poorest families in the us face citizenship poverty gender disparities and language barriers policymakers should deploy community level assistance that help engage these residents in government assistance programs 26 furthermore policymakers should evaluate the efficiency of energy assistance programs on a regular basis and tweak them as necessary while this research highlighted how energy efficiency programs fails there is not much research into the success of energy efficiency policy some works show the potential of benefits of energy efficiency implementations 2728 but they only illustrate potential not actual results given how important energy efficiency is to the clean energy transition research showcasing successful programs and identifying how that success can be replicated is essential nonetheless policy should focus on how to target lowincome households so that these policies improve energy equity efficacy of energy policy the efficacy of energy efficiency policy includes examination and assessment of policies designed to meet building and appliance performance standards typically through the uptake of green building certifications green building certifications like leed are rating systems that evaluate the sustainability and environmental impact of buildings they cover a range of factors including energy efficiency water conservation material usage indoor environmental quality and more the evaluation of such policies is crucial to understand their effectiveness costefficiency impact on promoting sustainable construction practices this could involve looking at various aspects such as the number of buildings obtaining certifications after the policy implementation the reduction in energy usage improvements in indoor air quality or the increased use of sustainable materials policies to encourage higher building performance standards or green building certifications can include financial incentives like tax credits or subsidies for certified buildings regulatory measures like building codes mandating certain sustainability practices or educational and promotional campaigns an effective policy evaluation would assess whether these measures successfully incentivize green building practices and result in a significant uptick in certification the assessment could also identify potential barriers or shortcomings thereby informing recommendations for policy refinement table 4 lists a select set of papers that investigate the efficacy of energy efficiency policy that aim to improve building performance standards local and federal policy can increase uptake in green building certification however energy consumption information is not available for these buildings making it difficult to measure the real impacts of greening a retrofitted building keady et al 2021 31 energy justice gaps in renewable energy transition policy initiatives in vermont used an antiresilience framework a perspective that highlights the need to change existing structures of inequality rather than just helping individuals adapt or become resilient within them finds that marginalized groups are more likely to face energy vulnerability as they lack access to sufficient and affordable energy furthermore nonwhite and renting respondents were significantly less likely to report having solar panels suggesting that the benefits of renewable energy policies are not reaching these vulnerable groups this research highlights the significance of energy efficiency policies and their potential to mitigate climate change and energy poverty 29 integrating energy efficiency policies with broader policies targeting the structural factors that lead to energy poverty 31 could lead to a more comprehensive approach to tackling the energy burden lowincome households face such as improving policy to encourage the adoption of green building 30 by promoting higher building standards policies can encourage sustainable construction practices and contribute to reducing energy consumption improving indoor air quality and fostering the use of sustainable materials 2930 however the effectiveness of these policies varies and as a result these tools should be used to present communities with feasible solutions and have them discuss internally which set of solutions best fit their needs 32 the research presented in the table suggests that an interdisciplinary approach incorporating various academic disciplines can enhance the planning and evaluation of decarbonization efforts ultimately leading to a more equitable and climate resilient future this echos work done showing the synergy of aligning energy with other sectors like transportation water or agriculture to reduce emissions and lower costs 2733 however as mentioned in the energyefficiency efficacy section the lack of research exploring successful examples limits the impacts by not providing a blueprint for successful action this research does an excellent job on illustrating why incorporating equity is important and providing potential frameworks to do so but does not yet show what those successes look like as the effects of various new subsidies and laws take effect there will be opportunities for researchers to evaluate positive examples that detail how they can be replicated the clean energy transition and energy justice the clean energy transition is the process of shifting from traditional or nonrenewable energy sources like fossil fuels to new sustainable and renewable energy sources such as wind solar and hydropower social inclusivity suggests that this transition should not just be about technical changes but should also consider the social dimensions of energy systems it should contribute to social equity by ensuring fair distribution of energy resources and benefits across all societal groups especially marginalized and vulnerable communities this can be encouraged by focusing on several key areas • community engagement where communities that are marginalized are actively involved in decisionmaking processes related to energy transition their input and feedback can guide the development of energy projects that meet their needs and respect their rights • affordabilitythe cost of new energy technologies can be a barrier to access for lowincome households policies and initiatives should aim to make renewable energy affordable for all to ensure broad adoption • job creationthe energy transition can create jobs in the renewable energy sector training and educational programs can ensure that these opportunities are accessible to people from diverse backgrounds contributing to social inclusivity • energy justiceenergy transition should aim to address historical inequities in energy access and the impacts of energy production this involves reducing pollution in marginalized communities and ensuring fair access to the benefits of renewable energy tables 5 and6 list a select set of papers that investigate the how the clean energy transition can address energy poverty and support energy justice this is by far the largest section and it shows that energy poverty researchers see the clean energy transition as an opportunity to address many longstanding equity issues and are generally positive about the future the findings suggest that while the mechanism of direct electricity bill reduction can provide some relief it does not necessarily contribute to restorative justice via wealth creation the paper concludes by proposing specific policy and program recommendations to ensure that the benefits of utilityscale pv systems are properly distributed to underserved communities thus contributing to a more equitable energy transition recent technological developments to enable the transition towards environmentally friendly energy sources have opened opportunities for the government to support the reduction in energy burden although previous scholars demonstrated the potential of technological developments 272841 especially solar energy sources to reduce the energy burden of lowincome households racial and ethnic minorities still face the barriers to get the government funding for the assistance programs 223437 these reveal the gaps of the energy transition and the potential opportunities to combat climate change and support energy justice 40 furthermore these research papers underscore the importance of incorporating energy justice principles into the deployment of renewable energy systems and having an overall energy justice framework for the clean energy transition 63639 moreover they highlight the complexities and challenges associated with climate induced changes in electricity systems and how certain interventions can have an outsized effect now 3538 by addressing these issues the energy transition can move towards a more inclusive and sustainable future ensuring fair distribution of benefits and mitigating the adverse effects of climate change this theme will inspire numerous other articles on how the energy transition can be successful however as mentioned in the efficacy sections as successes appear work needs to be done to illustrate how to replicate those successes furthermore most of the energy poverty work is focused on electricity use in buildings but as vehicles electrify energy poverty will be more clearly tied to transportation poverty and those issues will have to be addressed as well overall the clean energy transition provides a plethora of topics to investigate and energy researchers have plenty of space to explore from the policymakers perspective many of the decisions they make to address climate change will have a positive impact on energy justice however the ordering of these policies could benefit disadvantaged communities much more quickly for the same costs policymakers will have to acquaint themselves with the possible decision sets and researchers will have to educate them when decisions can improve equity and climate simultaneously especially in the instances when there is no extra cost discussion energy poverty and justice are critical issues that demand comprehensive attention and action as an evolving concept energy justice aims to address disparities and injustices in the global energy system through equitable energy distribution inclusive participatory processes and transparent procedures this review paper shows that research has shown relationships between energy poverty and social disparities which could vary depending on the specific metrics and scope of the research the research underscores the interconnectedness between energy and other social disadvantages demonstrating how limited access to affordable and reliable energy services exacerbates existing social inequalities including income disparities racial and ethnic disparities housing disparities and health disparities it emphasizes that energy poverty has multidimensional impacts on individuals and communities extending beyond mere energy access it affects various aspects of wellbeing including health economic opportunities and environmental justice amplifying social disparities the research highlights that energy poverty in the context of social disparities is influenced by systematic factors such as income inequality residential segregation and historical socioeconomic disadvantages it recognizes that addressing energy poverty requires addressing the root causes of social disparities and systemic inequalities we have also come across research that emphasizes the importance of developing and implementing equitable solutions to address energy poverty it stresses the need for policies and programs that prioritize the needs of disadvantaged communities promote access to affordable and clean energy improve housing conditions bridge the digital divide and ensure equal opportunities for health and economic development this is especially important as the world transitions to new clean energy technologies the clean energy technology provides an opportunity to address many inequities but only if policymakers explicitly include equity considerations in their plans furthermore the efficacy of energy assistance programs and energy efficiency policies must be continuously evaluated to ensure that they effectively target and alleviate energy poverty addressing energy poverty and promoting energy justice requires a collaborative effort from policymakers researchers communities nonprofit organizations and businesses by integrating ethical considerations into energy policies embracing social inclusivity and adopting sustainable energy practices we can work towards a more just and inclusive energy system that fosters social equity environmental sustainability and overall wellbeing for all individuals and communities conclusions and future work this paper critically reviews past research on energy poverty in the themes identified by the nsf 2026 priorities and research needs for an equitable energy transition workshop and the united states department of energys office of energy justice policy and analysis as research priorities for an equitable energy transition in the us we conclude with our main findings and directions for future work our research allows us to draw a number of conclusions first energy poverty is a complex issue that requires a comprehensive assessment of the socioeconomic characteristics of households housing quality household energy consumption related to geographical and climatic conditions as well as the access to energy efficient technologies and energy costs however this comprehensive assessment must go beyond commonly collected statistics that help calculate common metrics such as energy burden and provide context for the energy circumstances of potentially vulnerable households and populations second energy behavior significantly influences energy consumption and the implications of energy justice policy for the sustainable and just energy transition household socioeconomic characteristics culture environmental education and awareness influence energy behavior a comprehensive understanding of how households not only use energy but also limit their energy use and interact with their energy providers may help policymakers implement more effective policies third despite the progress of energy assistance programs in providing financing and incentives for energy justice many of the most vulnerable households in the us face structural obstacles that preclude them from influencing policymaking our research revealed one critical literature gap the need to understand successful energy efficiency policies to expand policies and serve vulnerable households more effectively fourth past literature highlighted the potential of energy policy to support energy efficient and energy just buildings and communities however the effectiveness of energy efficiency policy significantly varies because many projects lack a comprehensive understanding of the energy efficiency needs of communities fifth the energy justice principles prioritizing the meaningful inclusion and engagement of vulnerable households facing energy poverty may pave the way for a sustainable and just energy transition past literature highlights the significance of a comprehensive examination of the varied dimensions of energy poverty including the inequities in energy and transportation poverty the energy transition may serve to address a plethora of energy injustices to reduce energy consumption and improve the living conditions of the most vulnerable households future research should focus on examining how multidisciplinary projects and programs that effectively and democratically engage vulnerable communities communitybased organizations industry and governments can be scaled and replicated eliminating energy poverty and achieving energy justice is a continuous fight one that although the clean energy transition may aid in researchers practitioners and other stakeholders will have to continuously and collaboratively work on to win data availability statement data sharing not applicable no new data were created or analyzed in this study data sharing is not applicable to this article author contributions conceptualization ecjj methodology ecjj validation ecjj and ar formal analysis ecjj data curation ecjj and ar writingoriginal draft preparation ecjj and ar writingreview and editing ecjj and ar all authors have read and agreed to the published version of the manuscript funding this research received no external funding

energy poverty affects numerous households across the globe and has several key implications and concerns for public health and social equity energy poverty is defined as the lack of access to modern and affordable energy services

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introduction traditionally it was affirmed that the main reason for womens migration is the submissive role within family structures as wives mothers and daughters however in the last decades many scholars agree with the notion of the feminisation of migration arguing that the migrant women population has increased to look for better living conditions employment and education among others nowadays the number of women migrants is the same as that of men women are not moving only for marriage conditions but also because they become the primary economic support of their families although this change gave more independence to women it was not a complete victory in womens struggle for equality in the patriarchal system unfortunately it is still possible to identify in the migration patterns gender gaps that discriminate and affect womens rights as a result women continue falling behind and being vulnerable to exploitation and violence this led to the topic of this paper where i discuss one part of the correlation between gender and local integration focusing on the research question why local integration processes are different for women and men as a reference the local integration process of women refugees and migrants from venezuela in colombia from 2018 to 2021 to respond to this question the paper contains qualitative and quantitative information at this point it is necessary to mention that a wide range of interdisciplinary analyses and literature exists about local integration women and migration therefore it was challenging to delimit the literature sources and considering the little word this paper does not cover a complete analysis of the panorama but it remarks on the topics most important ideas and elements considering that there is little literature about the experiences of local integration and migration of women inside latino america the qualitative sources reinforce the theoretical perspective of the topic and the quantitative data support the single case of study the paper refers to the most known and agreedon definition of local integration and its main elements additionally develop the implications of the gender conceptions and practices in connection with local integration and the theoretical perspectives are linked with the case of the study this case was chosen for two reasons currently the displacement of venezuelans is one of the most significant humanitarian crises in the world and on the other hand colombia is one of the few countries that has implemented an open and flexible migration policy to welcome migrants the main finding of the research is that there is a gap between the local integration processes between men and women the paper argues that the existence of legal norms for the reception and protection of migrants and refugee women in the host countries is not enough to guarantee their agency and access to resources to achieve local integration daily migrant and refugee women face situations and practices that limit and undermine their autonomy leaving them in highly vulnerable conditions the paper is divided into four chapters the first part reviews the literature about the meaning of local integration and the most critical conditions or elements next the outcomes and features of womens experiences in local integration processes are developed the third part exposes the case study data of venezuelan migration in colombia emphasising womens conditions finally the fourth chapter concludes with the most important ideas and facts local integration local integration has been recognised as a durable solution since the beginning of the refugee regime it offers permanent asylum and complete integration in all systems in the host country it means that people should have full rights including the recognition of their residency and citizenship therefore they could participate and be integrated into all activities as a person born in that country however there is extensive literature from different branches of study law sociology economy and demography describing what consists of local integration based on the ideas of polzer local integration is a social and political process of negotiations under a system of powers and interests between the refugees and the actors present in the host country that can happen in the medium or long term this process is not entirely dependent on a legal or institutional framework because it is based on the agency and capacity of the parties to negotiate a trade of profits between them for that reason the needs of refugees are determined by the facts and conditions of the context and resources more than by a set of rules and institutional guidelines castles korac vasta vertovec describe integration as a process given in a double way and multilevel dimensions with this the authors refer to integration as an interchange between all people the displaced population and the hosting one who coexist and have the will of adapted to changes under the same conditions and rights at the same time migrants and refugees conserved their identities and sociocultural practices even when they represented a small group of society this definition has a vision founded on plenty of guarantees of rights and conditions for all parts silver indicates that social inclusion may refer to a process of interconnection and interactions between people that improve the opportunities to participate in different dimensions of public life and strengthen the integration solidarity cohesion and recognition as us these factors reinforce the affirmation that local integration is a concept that not only needs to be understood analysed and tackled from joint and interdisciplinary perspectives but also as a process where the agency and capabilities of people play a decisive role considering the diversity in gender ethnicity culture and even their autonomy the last essential point to consider in the definition of local integration is the construction around the idea of community as castles korac vasta vertovec mentioned the essential part of the integration process is creating solid communities even when there are differences in cosmovision and social practices among people this aspect is essential for talk of real inclusion because belonging and affinity to a community are more complex notions that implicate social dynamics relationships and the recognition of others which are concepts closer to the idea of social inclusion women and local integration in general women migrate as much as men in 2020 were 281 million migrants worldwide and 48 of this population were women however womens rights recognition and inclusion continue to challenge social and political practices the framework of international laws continues to have an androcentric approach to protection identification of vulnerabilities and response mechanisms an example of this is the refugee convention of 1951 since was not include specific categories related to human rights violations and other affectations based on gender issues after hard work led by feminist activists in 1979 with the convention on the elimination of all forms of discrimination against women rights became more visible also in 1990 genderspecific and genderrelated persecution began to be part of the international framework of refugee status determination although the proportion of women and men migrants is equal they migrate for different reasons and conditions as explained by lee one of the factors that one person takes into account to decide to migrate is personal issues in this sense some people do not choose to leave their country of origin alone but are motivated by life cycle elements this is observed in the family relationship where children travel with their parents and wives with their husbands in this way bredtmann otten highlight the importance of the relationship between the cultural background of migrant women and the roles that they assume this research suggests that womens labour supply and integration depend on the host countrys economic cultural and social conditions and the beliefs and preferences that shape the social roles in migrant families and communities these factors define notions such as parenting couple and family relationships similarly manchanda argues that culture and traditions are constantly transforming especially in critical situations such as displacements where gender roles could blur because of the changes as a result the migration process is shaped by gender ideologies and vice versa how the family structure conceived the norms of relationships and gender roles influences womens migration conditions and motivations for instance in most migrations of communities with a noticeable patriarchal system the roles of gender are reinforced and practices as the control and prohibitions increased on the contrary in other situations migrations can be an exit from a traditional restricted and rigid system of believers and women can seek productivity autonomy and freedom a third possible scenario during migration is when men leave behind women and children the women are obligated to acquire new roles for example being the suppliers of the household generating more income than before and at the same time looking after the dependent members of the family therefore the womens burden rises and they are obligated to enrol in jobs or activities with precarious conditions in terms of salary and labour rights and are more vulnerable to being harassed additionally pittaway bartolomei mention that during migrations and in the host countries women are exposed to being doubly discriminated against and othering firstly in some countries the migrants are seen with lesser value and as competitors and adversaries because of a threat to the culture identity and economic system one of the most common situations is the labour market where some migrants are willing to accept jobs with fewer salaries than locals and without guarantees and demands secondly in patriarchal social structures women are discriminated against by gender and seen as weak and secondclass as a result they are private of rights and profits this discrimination is visible when women are limited to participating in activities related to domestic work the sexual industry or informal sellers also they have difficulties accessing services and attention from state institutions in health services reproductive rights education and law protection in cases of being victims of rape exploitation and sexual abuse among others race caste and ethnicity also trigger discrimination xenophobia and discrimination particularly in countries with profoundly different cultural religious and economic backgrounds in the specific case of colombia and venezuela the populations share similar costumes traditions and histories therefore discrimination for race or caste does not become prevalent however despite the social affinities between the two countries xenophobia discrimination and marginalisation have been evident in the local integration process and even in the discourse of shared citizenship and local politicians as a result of how gender is delimited and conceived women face many challenges in the local integration process the process is much slower narrow and more restricted than men consequently the power relationships are unequal as seen in their daily living conditions and needs moreover they must try to obtain resources for their survival and on many occasions for their children and other dependent family members some effect of this is that women have fewer wellbeing conditions than men and have fewer opportunities for decent employment in addition participation in the training process is also limited by their roles allocated in the household taking care of the children and elder people in this sense traditional gender norms have contributed to the genderisation of jobs it means that jobs where most women migrants work are considered unskilled and casual these occupations have the lowest salaries and conditions and the most common is domesticprivate jobs as cleaners housekeepers and caring for older people and children traditionally caring work has been considered a women job because it is a continuity of their occupations and role in the household therefore women have a work burden trying to fulfil the responsibilities with their jobs and dependants including partners in matters of alimentations laundry and so on the conditions that refugee and migrant women face in the integration processes generate significant challenges that cause women to have more difficulties achieving favourable conditions for their wellbeing constructing protective and inclusive environments where women can count on tools that allow them to make decisions free of risk factors social pressures rejection and pointing out are indispensable for real integration methodology it should be noted that the sources of information on the migrant population in countries such as colombia are scarce however it is possible to have official sources of information that show a general panorama of the needs of the migrant population the gran encuesta integrada de hogares is a survey that provides information on peoples employment conditions sex age marital status and educational level and sources of income at the national and municipal however the territorial scope of the survey is limited because it is impossible to have data from the 1099 municipalities of colombia therefore the module of the migration data of people arriving in colombia has limited information especially in the municipalities located on the border with venezuela due to the permeable borders and the absence of immigration control however the data used allows for a reliable statistical approximation at the national level the geih universe comprises the noninstitutional civil population residing in private households it also excludes households that do not remain in residences or those in transit to other places therefore the unit of analysis in the case of the geih and this study focuses mainly on people for the corresponding sample size analysis the primary expansion factor applied to the sample data in this case of people is taken as a reference and gives each sample element the weight or representation corresponding to it in the investigated universe regarding the migration module of the geih this allows information to be obtained from migrant groups or profiles of the venezuelan population with a vocation to stay colombian returnees and the host community nevertheless the survey records do not allow for knowing about migrant profiles such as the pendulum population at the borders people in transit to other national or international destinations and homeless people this is due to the surveys focus and its collection methods being by telephone which excludes another type of population that does not have the means to access or record their data due to the large number of data obtained from the geih it was necessary to use programming languages to process the databases in this case stata worked with databases like this and processed many observations likewise the operations carried out the linear and probabilistic regressions facilitating information and analysis for the analysis of the data using stata the last month for each year was selected from the databases that is the month of december taking as a reference from 2018 to 2021 to make the respective annual comparisons and in this way obtain the variations between what was 2018 and 2021 the selection of the year 2018 is crucial because it was the accelerated beginning of the migratory phenomenon of the venezuelan population to colombia compared to the year 2021 which is the last year that registers complete annual figures and where it began a process of migratory stabilisation at least understood from the numbers of migrants who came to colombia especially after having experienced exponential growth as the study focuses on the migrant population it was necessary to glue the bases between the geih and the migration module which being complete allows data to be obtained from those groups of migrants who belong to the classification of persons with venezuelan nationalityjust highlighting that they are of the vocation of permanence in this paper regressions are carried out applying linear and probabilistic methods from the data obtained from the geih to determine the relationships and causalities between the selected variables for this it was necessary to make the respective binary classification for some of these and thus determine what type of population to classify or compare it is essential to highlight that for the regressions those statistically significant variables must not exceed after that value the relationships between variables may not have substantial differences or are not statistically relevant the employment variables for example are determined by whether they have a verbal or written employment contract without this implying knowing if this was a formal or informal job their classification is done binary where one is that they have a contract and 2 is that they do not the income variable being a continuous variable was considered if it was reported by the respondents who mentioned having income and what they did not earn for variables with more response options grouping them by response options was necessary colombian case historically colombia and venezuela have had a solid dynamic economic and cultural exchange more than 2219 km of land border connects both countries in different regions along this border there are seven formal points of the migration authorities however it is a fact that there are also hundreds of irregular pathways that illegal groups use for human drug arms trafficking and other illicit activities and economies therefore the border between colombia and venezuela is highly permeable taking into account the geographic features and the capacity of the state the control of government institutions over the territory is complex and challenging in 2017 the government issued the first temporary permission to regularise venezuelan migratory status and allow them access to employment and social protection system but only for those who enter colombia legally through mobile points and with a passport however more and more migrants arrived in colombia under unprotected vulnerable conditions and irregular status therefore in 2020 the colombian government released the last regularisation document for venezuelans named temporal status of protection this new certificate extended the conditions regarding time and benefits for people hence people can access this permission until 2023 only with a national identity card and could stay in colombia for ten years with the right to do any legal activity or occupation access to education and health services in this sense the execution of the tsp has a double purpose firstly the objective is to regularise all venezuelans to secure their economic contributions by paying different taxes also it is essential to have an entire panorama with feasible data about how many venezuelans there are in the country and their conditions to design and implement public policies oriented to manage issues related to integration security and legal processes secondly the tsp is an act that represents the disposition of the colombian government with the international treaties signed and the commitment to the guarantee of human rights considering the migratory actions adopted by the colombian government these policies can be seen as measures of local solution local solutions are defined as complementary actions facilitating the transition to local integration as a durable solution these measures are temporal and allow refugees to participate mainly in the host countrys economic social and cultural aspects including obtaining permits for residency and inclusion in the formal labour market for some time the objective of local solutions is to allow vulnerable displaced populations to be empowered and promote their selfreliance and agency at the same time the process of total inclusion moves forward in this sense local solutions could include a range of rights related to livelihoods and social protection services but not with the guarantee of political and civil rights which are granted just under citizenship recognition the following graph provides information about the main reasons venezuelan people have migrated in the last year and allows make some assumptions about gender and migration in the present study case the first finding in this data is that two main reasons supported the decision to migrate for women and men accompanying family members and working in first and second place respectively nevertheless the gap between the first and the second reason in women and men is notable in this sense even when both populations migrated for the same reasons women migrated more than men for familiar reunification the most recent data on the conformation of venezuelan households is from 2019 where 41 of men indicated being the head of their home compared to 17 of women besides 38 of women identified themselves as partners or wives to the contrary men only 8 indicated being the partner of someone this information suggests that traditional gender rules are an essential factor in the migration pattern of venezuelan people to colombia notably the significance of men as heads of households is noticeable in the family structure employment from source dane geih as seen in the previous graphs despite most of the women population having permission to work and being in a productivity age during the last four years they were less involved in working activities or employment which generates any remuneration graph three shows the difference between venezuelan women and men at the moment to access employment under contract conditions the gap has remained during the last few years which means that women are exposed to unfair labour conditions where they are vulnerable to exploitation receiving meagre salaries not having access to labour rights and being part of the protection system of the state graph 5 number of venezuelans by salary range 20182021 exchange rate 4167cop1usd basic salary in colombia 268 usd source dane geih this graph illustrates the remarkable difference between the incomes of women and men in some salary ranges the number of men who earn money is double that of women also as the salary increases the participation of women decreases except in 2018 and 2019 where it can be seen that in the third salary band the number of women with salaries was significantly higher than the men however in the following years the participation of women decreased widely there is limited evidence for knowing the causes still considering the countrys context it is possible to assume that this decline was due to the beginning of the covid19 pandemic that affected the labour market however it is evident the disadvantage of women over men another essential point is that in some salary bands the number of women is cero health services graph 6 number of venezuelan affiliated with some health institutions 2018 2021 source dane geih in the variable about access to medical services the percentages between men and women are similar for affiliation and not affiliation however the venezuelan population without access to services is an essential factor in the local integration process even though the colombian government has facilitated access to health services an essential number of venezuelans are not affiliated with the social protection system of the state this is due to the informal labour market the irregular status and the lack of knowledge about the affiliation process in 2021 the affiliation of men to the contributive regime for the social protection system was 15 more than women which suggests that men had more access to formal employment education according to the chart in the last years most migrants and refugees from venezuela to colombia are population groups with primary and secondary education levels both women and men additionally most men and women reached secondary school as their highest educational level however as shown in the graphs above the gap is evident in access to employment with fair conditions and better wages on the other hand the percentage of women from venezuela with technical and professional levels of education is superior to that of men consequently they are more qualified to enrol in employment with specialised requirements despite this there is a barrier to validating professional degrees because the process in colombia is extensive and detailed to avoid false degrees and ensure educative standards regarding the access to education of adults the data found are general until july 2021 276 of the yes total enrolled students in educative institutions were between 17 21 years old and 153 were people more aged than 25 years old graph 7 education level of venezuelan people in colombia source dane geih housing graph 8 type of housing of venezuelan households source dane geih from 2018 to 2021 the type of housing more common for the venezuelan population has been renting the distribution between men and women is similar in this category the second type of housing is under usufructuary agreements when the tenants do not pay in this case women have lived more in this type of housing than men also in the category de facto occupant women have meaningful participation indicating their living conditions vulnerability the information in this category makes it possible to deduce that the risk of eviction of many venezuelan families is high considering their type of housing and the economic conditions in a country like colombia with significant levels of unemployment results and discussion this section aims to analyse the main elements of the local integration process in colombia making probabilistic and linear regressions between the variables more meaningful and pertinent for the papers discussion this allows for identifying the probability that a series of characteristics belong to a given group compared to another therefore they are handy for understanding what causalities can affect a population and discussing some assumptions about the conditions of women refugees and migrants venezuelan in colombia and their participation in local integration the previous relationship might point out that regardless of the educational level women have reached they are 41 more unemployed than men with the same academic levels however there is no significant variation to assume that the education level of women and men generates a gap between both population groups regarding an activity such as looking for a job in this sense the data suggest that women have fewer opportunities and more challenges than men in access to employment in general one of the most critical factors for local integration is the inclusion and participation of refugees and migrants in the economic market this facilitates the possibility of having incomes to supply their needs and interact with the host countrys population in other spaces of society nevertheless for the integration of women access to employment is even more critical because it allows them to be selfreliant and autonomous and have the tools to break traditional power structures the access of women to economic sources has positive effects in different aspects they acquire a more relevant position within the households that positively influences genderrelated norms they can support and promote the development of capabilities and human capital in the young generations living with their children cousins nephews nieces and siblings in addition the participation of women in the economy and the processes of growth help to improve the distribution of resources and the generation of development in a country negotiate seems to be reduced by how gender is perceived in society and the power systems even when women have tools such as education or training in specific activities their disadvantaged position can be reflected in situations like working without any formal contract or receiving less salary can be very common on the other side in light of the perspectives of bredtmann otten the results suggest that in the cultural system and social norms in venezuela the role of the man as the supplier and the woman as the one in charge of raising and caring for the children is still dominant additionally this could promote dependency relationships between women and men and in turn situations of violence and other manifestations of patriarchal culture this approach could be complemented with data for example the violence based on the gender of venezuelan women in colombia between 2018 and 2021 the violence based on gender against venezuelan women increased by 71 also 8095 of these cases were violent domestic situations generated by womens partners another essential point from the above results is that it could be supposed that gender roles also affect the salaries and the type of jobs that women can access the genderisation of the activities and employment promotes the marginalisation of the women population because most work for women is related to activities that do not need specialised knowledge therefore women are relegated to activities that are not highly valued and are related to domestic work cleaning or sexual services the difference between the salaries of both populations might increase the dependency on men and their control over resources additionally it could increase the risk and vulnerability in situations of labour exploitation health effects due to sexual contact diseases domestic and public violence due to being exposed to more significant risks due to work that implies their permanence on the street and the risk of being victims of human trafficking or smuggling the data would seem to indicate that women are 5 more likely to leave venezuela to accompany other family members than men as explained by lee it could be thought that women decided to migrate due to motivations related to the familys meaning and their role as wives and mothers rather than for entirely personal reasons moreover the data suggest that the chances of having a verbal or written contract to work for women are 10 less likely than for men however the chances of having some verbal or written contract increase by 12 for women with a higher education level as well as the difference between the salaries of venezuelan men and women the lack of contracts at the time of carrying out an activity that generates some income or benefits could be considered a way of discrimination against women in their participation in the labour market the bias decreased access to protection social systems and health or pension funds even though the previous results could indicate a broad relationship between the realities faced by migrant and refugee women from venezuela in colombia and the literature that supports the argument of this paper it is considered that there is a lack of information in the followup of the local integration process of women this gap can be identified in the absence of data from a gender perspective due to the lack of information on the specific conditions and situations that women must deal with in the process of local integration in this sense it is essential to highlight that migrant and refugee women are not a homogeneous group their life stories and decisions are influenced by different factors such as the causes of their mobilisation or displacement their educational levels age social class the family structure to which they belong their economic activity and other norms and beliefs that define their skills and abilities to face a local integration process in a new and unknown country this research contributes to understanding the migration process with a gender approach particularly emphasising womens situation it might be considered for the policy design implementation and evaluation debate during local integration processes moreover it can help to understand the recent experience of womens migration inside the latinoamerican continent the limitation of this research is that it is based on secondary qualitative and quantitative data therefore the feasibility and precision of data are not dependent on the researcher at this point it is essential to mention that the only source of quantitative data for the study case is a national survey done by the colombian government the specific literature about the local integration process of venezuelan women in colombia is little and uses the same survey as a quantitative source therefore no more data is available to compare or complement the different variables and the surveys limitations conclusion this paper has presented the main arguments for why local integration processes differ between men and women considering the most widely accepted definition in the literature and practice as a starting point a parallel has been established between different gender perspectives and their implications for developing a local integration process for women in this way it has been shown that traditional gender norms can shape local integration processes often based on a patriarchal system and distribution of power and resources where women have been violated discriminated against and marginalised the results of the previous exercise also have evidence that even when existing legal protection guarantees and coverage for refugees and migrant populations there is a gap between the processes of local integration between men and women the empirical data concluded that refugees and migrant women faced more challenges than men in achieving local integration this finding was supported after first comparing the most important elements of local integration between men and women and later statistical regressions of the most significant variables of the first exercise the prevalence of patterns reinforces social practices such as exclusion and inequity that cause lag and disparities in local integration processes in all variables associated with the main elements of the local integration process the data related to the women population have shown the disadvantages in participation benefits and conditions compared with men in other words the durable solutions are gendered in terms of access experiences and implications considering local integration as a unique and generalised process could promote and repeat structural violence and marginalisation especially under patriarchal structures local integration processes are narrow and restricted for women because the permanence of power systems based on patriarchy generates conditions that categorise women limit them and restrict their capacities this in turn causes inequality and a lack of recognition and women continue to live under vulnerabilities and risks that threaten their wellbeing and dignity in this sense women have fewer opportunities to access employment even with academic education additionally women are more exposed to working under unfavourable conditions such as reduced wages and lack of employment contracts which makes it challenging to access welfare systems such as the right to a pension affiliation to health services and the probability of being evicted of their homes due to a lack of income in line with what liebig t k tronstad and tastsoglou e mention the participation of refugees and migrants women in all areas of society especially in the labour market is decisive because they are the first responders in transferring experiences to children and in providing better conditions so that these future generations can have satisfactory integration processes where states of vulnerability can be overcome therefore it is necessary to conduct future research on the effects of local integration of women and the effects on the conditions of their dependents likewise it is considered essential to approach the study of local integration processes in women in a more profound and more specific way which takes into account all the challenges of women at an individual and social level to have detailed tools for rethinking local integration policies with a gender perspective and not with generalised measures dydx is for discrete change of dummy variable from 0 to 1 the table would seem to indicate that women are at home doing domestic and care work 41 more than men it is a situation that puts a stigma on women because regardless of whether they have a level of study or not they will find themselves carrying out household activities in addition it might be assumed that the marginalisation of venezuelan women has a background in their origin country as can see in the level of education of this population the role of women inside the familiar structures the domestic work the childcare and the dependency on their partners the sociocultural patterns of genderbased roles end up being one of the most critical barriers to the local integration of women these patterns have a basis in the social institutions where economic cultural social and political behaviours are defined these behaviours are crucial for how others see women their participation in power relationships and the possibility of having agency the fact that women do more care and domestic work than men make local integration difficult for women there is no country in the world where men spend equal time on unpaid work as women do 1 for example the mental burden the burden of housework and childcare prevent women from accessing employment this unpaid work can be related to the lack of education opportunities subsequently the lack of technical capabilities and labour experience influences the possibility of employment with fair conditions and the capabilities to be economically independent in addition women heads of households or those engaged in domestic work have more significant difficulties participating in training or education programs due to their responsibilities with housework and restrictions on their free time as a result there is an essential tendency for men to participate in these spaces as beneficiaries before women the previous results suggest that women earn less income by 18 compared to venezuelan men however their educational level had no significant differences even if women had higher education levels according to the definition by polzer about the local integration processes in the colombian case it might be thought that the local integration of venezuelan women is slower than that of men it may be because womens ability to

this paper examines why local integration processes differ between men and women from a gender perspective the challenges that migrant and refugee women face in accessing rights and benefits are different due to the prevalence of traditional gender norms and the discrimination of power structures how gender is defined and conceived has shaped migration patterns the conditions during the mobilisation and the later circumstances in the host countries women migrants and refugees assume burdens related to sexist notions and ideas about their role in the world and they are excluded from most of the social cultural political and economic spheres necessary for the process of recovery adaptation and integration in the new contexts this study used qualitative and quantitative research based on a case study of refugee and migrant venezuelan women in colombia where was applied regressions with linear and probabilistic methods to determine the relationships and causalities between selected variables of the essential conditions to achieve local integration the results of the exercise evidenced that even when existing equality in legal guarantees for refugees and migrant populations there is a gap between the processes of local integration between men and women the empirical data concluded that refugees and migrant women faced more challenges and limited access to opportunities

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female genital cutting continues to garner increasing attention across western healthcare systems seeking to optimize care and outcomes among migrant communities affected by this practice besides clinical knowledge gaps healthcare providers may also lack an understanding of the historical sociocultural and geopolitical forces that undergird womens healthseeking behavior experiences with care and decision making through the lens of cultural relativism the target article by brady connor chaisson sharif mohamed and robinson presents a conceptual model informed by the theory of planned behavior which guides providers on how to engage in culturally sensitive discussions and shared decision making on fgcrelated care with patients their partners and their families in this commentary we highlight the flux of migratory and acculturative processes and the prevalent hegemonic discourse which continually reshapes the embodiment of fgc and may implicitly influence womens decision making regarding defibulation management attitudes norms and control in flux acculturation is a process of social psychological and cultural adaptation that takes place over a period of time as differing cultural groups adjust to the prevailing cultural norms of a given society it also considers how crossborder transnational social networks reinforce cultural norms from communities of origin in the context of migration among fgcaffected populations proxies of acculturation have typically relied on such factors as english fluency language preference age of first arrival and length of time in the host nation multidimensional scales are increasingly being developed to capture the extent to which migrants may concomitantly derive their identity from both their country of origin and their host country research is only beginning to elucidate how the acculturative experience may impact utilization of healthcare services and disparities in health outcomes using contextdependent and validated metrics of acculturation the fluctuation of beliefs and behaviors inherent in acculturation should be considered in conjunction with the tpb which posits that intention to engage in a behavior is based on ones attitudes perceived norms and perceived autonomy with respect to this behavior the convention of fgc and its sociocultural norms evolves in the context of migration coined by berg and denison as a tradition in transition global migration from countries where fgc is highly prevalent to those where the practice is uncommon criminalized and stigmatized precipitates a cultural shift in attitudes and decline in support among diasporic communities the underpinning forces that perpetuate and hinder the continuance of fgc are subjected to crosscultural scrutiny and pressures that prompt a reconsideration of the practice while a crosssectional study in norway suggests that a shift in beliefs generally occurs after 4 years in the west the fluidity of shifting attitudes toward fgc in conjunction with attempts to preserve sociocultural norms amidst an increasingly hostile geopolitical climate toward migrants suggests that acculturation is not at all linear a qualitative study in norway found that while somali and sudanese migrants possessed negative attitudes toward infibulation due to its inherent health risks they also opposed premarital defibulation when considering fgcaffected womens decisionmaking processes regarding intention to pursue vulvar reconstructive procedures it is critical to understand how attitudes toward fgc perceived norms about the practice and autonomy in decision making may be influenced by such acculturative processes and the maintenance of social networks both within diasporic host communities and communities of origin furthermore understanding how a migrant womans personal perspectives may be influenced by social interactions and interpersonal relationships may shed light on their motivations to seek care and their autonomy in decision making regarding fgcrelated care koukoui hassan and guzder posited that even geographic distance brought about by displacement does not shield diasporic women from matriarchal pressures namely by female elders however the dynamic acculturative forces affecting views of fgc also augment migrant womens control over decision making and husbands capacities to openly oppose fgc in the process of relinquishing sociocentric norms in favor of more egocentric western values the extended family may carry less weight in decisions surrounding infibulation needless to say such complex dynamics may not change predictably with acculturation consequently when interacting with patients and their families providers should be sensitive to and acknowledge these forces the othering of african womens bodies genital selfimage and iatrogenic pathologization upon arriving in the west migrant women with fgc immediately encounter the othering of those who do not uphold dominant societal norms linguistic accents scents hairstyles andor head coverings attire cultural norms religious practices and fgc status further accentuate this phenomenon while the practice of fgc is not limited to the african subcontinent being rather widespread throughout regions of southeast asia and the middle east special attention must be paid to the influence of racism and racialethnic stereotypes on the pervasive othering of african migrants with fgc in the west for healthcare providers to better understand this phenomenon experienced by a large subset of their patients with fgc black african women they must consider the historical traumas of slavery the exploitation of sarah baartman across 19th century europe as the hottentot venus and other racialized stereotypes of black womens bodies such stereotypes appeared as recently as 2012 when a youtube video 1 234 from swedish world art day went viral depicting a performance artist whose head was transformed into a 19th century minstrel blackface caricature and emblazoned on a barechested cake of a black womans torso the cake screams out in agony each time the swedish minister of culture cuts a slice of the woman undergoing faux female genital mutilation to add further insult to injury the minister occasionally feeds the very cake to the ailing woman sensationalizing and reinforcing the stereotype of the barbaric african amidst a surrounding sea of white faces who are reveling snapping photographs and eating the very mutilation cake such a depiction illustrates how the hegemonic discourse around fgc can swiftly exert deleterious impact whether overtly or implicitly on womens embodied experiences living with fgc in the west while it is important to acknowledge the myriad harms of fgc it should not be assumed that all women experience harms the extent and manifestation of which must be considered against the backdrop of exposure to other past traumas and victimization resulting from war forced displacement rape forced marriage and domestic violence among diasporic populations a holistic lens is necessary to consider the full range of factors which may impact sexual function in fgcaffected women without further stigmatizing them by only narrowly focusing on the state of their altered genitalia furthermore it is also critically important to distinguish the ethical debate surrounding genital alterations performed on minors and consider the human right to bodily integrity and genital autonomy of all minors regardless of gender this must be further contextualized by the sociopolitical discourse around gender and race which are pivotal to the development of truly unbiased policy failing to do so further others nonwhite migrant womens bodies some diasporic women with fgc may maintain the dominant view from their homeland of fgc being beautiful pure hygienic symbolically meaningful and enhancing ones femininity while largescale empirical evidence is lacking several qualitative studies have described women being disconcerted and unsettled by their genital appearance postdefibulation feeling abnormal too open exposed or like an empty space many of these women are conflicted between function and aesthetics between their ability to now engage in penilevaginal intercourse without pain yet experience distress in their postsurgical vulvar appearance such cognitive dissonance is augmented by the realization that while they may place supreme value on upholding cultural mores and aesthetics their partners and providers may prioritize functional outcomes discomfort with genital appearance postdefibulation is further complicated by the fact that reinfibulation is criminalized throughout much of the west in those nations where legislation does not explicitly outlaw reinfibulation it is strongly denounced by professional organizations who admonish providers to refuse such patient requests considering it a form of medicalized female genital mutilation while concomitantly oblivious to the moral doublestandard that condones female genital cosmetic surgery among consenting wealthy women despite the lack of longterm safety and efficacy data since both reinfibulation and fgcs are primarily performed on consenting adults we argue that partial reinfibulationpartial defibulation5 should be reconsidered as fgcs rather than fgc among women with otherwise healthy sexual function and autonomy in requesting vulvar reconstructive procedures emerging evidence has delineated the general preservation of sexual erectile tissues important for sexual arousal orgasm and pleasure among women with type iiib fgc dispelling the sweeping generalized myth that fgc completely disrupts a womans capacity for sexual enjoyment which in and of itself can produce harm within the context of migration ubiquitous stigmatization stereotyping othering and bodyshaming prevalent in public sociopolitical fgc discourse may engender an iatrogenic pathologization that negatively affects the genital selfimage sexual selfesteem and sexual function of fgcaffected women adolescents exploring their sexuality are particularly subject to this phenomenon especially when engaging in relationships with partners outside of their own ethnocultural identity the cultural encoding of fgc is contextspecific with supportive sociocultural protections being lost once displaced from ones homeland creating traumatic stress and vulnerabilities both within and outside of the healthcare setting it is the trauma that arises years later through migration protracted displacement when a woman is informed of the negative biomedical and sexual consequences of fgc diasporic women with fgc migrate from a land where the practice grants legitimacy status and respect to a country where it is regarded as an egregious violation of human rights and where sanctions against fgc are more stringent the myriad information on its deleterious effects compels women to revisit their experience from an etiological perspective this new perception of fgc can trigger distress and at times the reification of trauma the power hierarchies displayed in the manner in which healthcare providers discuss fgc and surgical reconstructive options with patients may impact their healthseeking behavior and decision making research has documented providers pathologizing terminology such as mutilation andor statements of disfigurement narrow focus on the state of the genitalia while overlooking the primary reason for the health visit nonverbal bodily cues of shock and horror patronizing overtones and the parade of trainees and other healthcare providers to gaze upon the clinical case of the altered genital anatomy one patient with fgc said of her gynecological exam all of them just wanted to look at me i didnt understand why and nobody asked me while another added my genitals were on display a group of whitecoated staff came and looked and talked to each other with disgust such experiences can generate feelings of inadequacy discomfort shame and anger and are particularly impactful in light of inherent patientprovider power dynamics amidst engrained societal racial and cultural hegemony providers should be mindful of these dynamics before engaging their patients as teaching spectacles and must be very intentional and sensitive to the language and tone used in their interactions with their patients in tandem the demand for clitoral reconstructive procedures have burgeoned in recent years despite the lack of longterm data on safety and efficacy amidst an array of complex ethical psychosocial physiological and cultural conundrums some proponents encourage women to break with a culture that oppresses women basing their patients candidacy for surgery on their maturity and desire to become a free woman rather than appropriately outlining the risks benefits clinical indications for and anatomic expectations of surgical intervention and potential alternatives after psychosexual counseling and education until the media policymakers healthcare systems and providers adopt compassionate culturally relativistic and nonjudgmental approaches incorporating language that avoids othering migrant women with fgc patients will continue to grapple with the iatrogenic pathologization that occurs in their experiences with care in the west social determinants of health and their influence on distrust and healthseeking behavior nationalistic xenophobic antimigrant and antimuslim rhetoric have swept across much of the geopolitical discourse throughout the west against this backdrop fgcaffected communities have been under siege with threats of deportation airport searches national news headlinegarnering criminal investigations and fears of daughters being taken away for perceived risk of having undergone fgc as survivors of human rights atrocities and the victimization of war and conflict they are further plunged deeper into the shadows as hidden migrant communities underutilizing healthcare services and stymying acculturative processes social determinants of health such as limited access to affordable health us immigration and citizenship services 2020 or child care language barriers challenges navigating healthcare systems limited health literacy discordant beliefs about health and illness profound distrust of the healthcare system gender and ethnocultural incongruence between patients and providers experiences of discrimination microaggressions and implicit bias as well as providers lack of knowledge confidence and cultural sensitivity in caring for fgcaffected populations further compound distrust and fear due to the political environment a crosssectional study in oslo norway found that only 20 of somali migrants sought health care for fgcrelated concerns such profound distrust and shortfalls in healthseeking behavior ultimately manifests in disproportionate health disparities and adverse health outcomes practical considerations for clinicians and researchers before culturally informed discussions encompassing fgc as shown in table 1 of the brady et als target article can ensue healthcare providers must first comprehend the complex political historical sociocultural and societal contexts in which these discussions are taking place and how they are embodied only then can the framework of safety respect and trust between the patient and provider begin to be established and progress made toward shared decision making between providers and patients alongside concomitant enhancement in providers clinical counseling and surgical skills there are healthcare systemlevel factors that are important to consider in order to ensure equitable access to care for women with fgc of note it may be beyond the scope of practice for some family medicine providers and nurse midwives to perform defibulation outside of intrapartum care therefore referral networks are necessary to ensure that patients who opt for antenatal defibulation or defibulation outside of pregnancy are able to access these services moreover referral centers with specialized multidisciplinary expertise should be developed particularly in regions with scarce resources where providers may lack sufficient volume of exposure to maintain sufficient clinical competencies efforts should also be made to honor patients requests for intrapartum defibulation even when cesarean delivery is ultimately performed for obstetric indications varol et al consider the larger umbrella of issues that may be of importance to fgcaffected communities including economic empowerment gender equity intimate partner violence stigma reduction etc which may exert an influence on womens decisionmaking x x x foster publicprivate partnerships and multicenter collaborations in the pursuit of funding opportunities x x x 2016 future research should determine the appropriate timing route of anesthesia and location of defibulation procedures based on individual patient provider and healthcare systemlevel factors protocols must be established to optimize accurate clinical documentation using the who classification schema icd10 and cpt coding how these considerations inform womens decisionmaking regarding defibulation andor reinfibulation are yet to be clearly delineated and should be included in future research directives while certainly not exhaustive table 1 provides a list of some best practices that may serve as a guide for clinicians and researchers engaged with fgcaffected communities in conclusion this commentary sheds light on the dynamic hegemonic context in which patients attitudes norms and autonomy embodying fgc are being shaped besides the ongoing trauma of stigmatization and othering upon migration to the west african women are also thrust into the africanamerican discourse surrounding historical trauma from centuries of slavery structural inequities and racialized stereotypes healthcare providers and researchers have a responsibility to acknowledge these societal forces and intentionally work to earn the trust of their patients with fgc nurturing trustbased equitable partnerships with fgcaffected communities is a first step toward the development of best practices in optimizing womens experiences with care and outcomes it is imperative that healthcare providers enhance their competency concerning cultures in which fgc is practiced medical and surgical care algorithms and protocols as well as seek to engage a multidisciplinary referral network in optimizing care when counseling women on vulvar reconstructive procedures providers must compassionately and patiently work with their patients as they proceed through dynamic acculturative processes in facilitating shared decisionmaking being mindful of how innate power hierarchies and racial and cultural hegemony may influence the patientprovider relationship health care is a human right as such it is the responsibility of providers and healthcare systems to create environments in which patients feel valued safe and respected cultural religious political historical social and hegemonic forces are at play in reshaping the lived experiences of diasporic women with fgc living in the west we challenge providers and researchers not to propagate the same open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit iveco mmons orglicen sesby40 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

video featuring male performance artist makode aj linde whose blackfaced minstrel caricature echoes the racialized stereotypes of the postcivil war era in united states history wherein africanamericans were dehumanized and demeaned in the public media and entertainment with exaggerated facial features language movement character and deportment codifying blackness as primitive hypersexual and comedic youtu becomwatch vz8zlm hiw7y accessed 2620 2 jezebels erin gloria ryan 41712 swedish official gleefully cuts racist black lady cake delights onlookers jezeb elcomswedi shoffic ialgleef ullycutsracis tblack ladycake59026 72 accessed 2620

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introduction health systems that provide for universal patient access through a scheme of prepaymentswhether through taxes social insurance or a combination of the twoneed to make decisions on the scope of coverage that they secure such decisions are inherently controversial implying as they do that some patients will receive less than comprehensive health care or less than complete protection from the financial consequences of illheath even when there is a clinically effective therapy to which they might have access controversial decisions of this sort call for a public justification for covering or not covering a given treatment prioritysetting agencies play a key role in providing such a justification a recent who report recommended that national healthcare systems set up institutions to make reasonable and accountable decisions on the path to universal health coverage in a growing number of countries governments have already established expert bodies to this effect moreover even in countries that explicitly reject considering cost effectiveness in coverage decisions this stance is now being questioned for example one of the most influential medical societies in the us the american heart association recently announced that they would begin to use cost data to rate the value of treatments in their clinical practice guidelines and performance standards arguably because systemwide solutions for determining the scope of coverage are lacking in this paper we analyze the process of public reasoning of one prioritysetting agency in particular the uks national institute for health and care excellence we offer this case study for a number of reasons first since its establishment in 1999 nice has secured a high reputation for its work among informed observers in the uk and abroad attracting international policy tourists although sometimes criticized its processes of decision making are widely respected not least for their rigorous approach to the assessment of value for money in health care indeed nice international the institutes global arm plays an active role in advising other countries interested in setting up bodies for making explicit coverage decisions second nice has also been praised for its recognition of various procedural and substantive ethical values in its decisionmaking processes for example in respect to the former gutmann and thompson cite nice as operating an exemplary decisionmaking process in their influential discussion of the idea of deliberative democracy in respect to the latter nice has also been praised for recognizing a wide range of what it terms social valueslike fairness nondiscrimination and responsiveness to needas necessary components of legitimate decision making third in its sixteen years of existence nice has completed a large volume of work and correspondingly been the focus of a large amount of external commentary between 2000 and february 2014 nice published 306 technology appraisals ranging across interventions for conditions as diverse as cancer multiple sclerosis depression and anxiety it has thus built up a considerable body of case law alongside the formal statements of its decision protocols much of which has prompted political mobilization by patient groups vocal opposition by industry hostile coverage in the press and controversy among parliamentarians political activists and academicsespecially when nices decision has been negative and coverage for an intervention by the national health service has not been recommended nices body of work and the debate it has engendered therefore offers a rich resource for commentary and analysis more importantly as we shall show the intellectual development and modification of its policy principles provide us with important insights into practical public reasoning and healthcare priority setting in this article we evaluate nices approach to priority setting considering the extent to which its approach is reasonable in this we depart from the standard measure against which most prioritysetting bodies are evaluated namely the accountability for reasonableness framework on afr the justifiability of prioritysetting mechanisms is taken to consist almost exclusively of their procedural virtues that is the extent to which they are accountable for their reasonableness in our analysis by contrast we evaluate the substantive values of nices methods against the rawlsian notion of reasonablenessnamely the willingness to propose fair terms of cooperation and abide by them provided that others do to be sure the rawlsian notion of reasonableness also underpins afr and its relevance condition in particular which requires that health providers give a reasonable explanation of how they aim to meet varied health needs under reasonable resource constraints however our use of the test is more basic we consider how far the values used by a body such as nice may be reasonable in a rawlsian sense regardless of whether the body itself might be accountable by daniels and sabins definition of course despite this difference there is a sense in which our analysis complements daniels that is insofar as it shows some of nices reasons to be reasonable it also identifies a certain set of reasons as relevant reasons for action within afraiding daniels account on a point where he has thus far been somewhat vague altogether then this essay offers three things a finegrained account of how far nices approach to decision making may be considered reasonable a new structure for assessing the ethical justifiability of public reasoning in prioritysetting agencies in general and finally the identification of a certain set of reasons as relevant reasons for action in the distribution of healthcare resources our argument proceeds as follows in section 2 we set out the nature of nices process we argue that nices use of evidence on a given technologys cost effectiveness is often wrongly described as a maximizing strategy instead we suggest that nices use of costeffectiveness data is best understood as a satisficing strategy wherein nice assumes a presumption not to fund interventions the cost effectiveness of which is below a minimum threshold we also stress that in both theory and practice nice takes this presumption to be rebuttable that is the presumption to fund interventions below a given costeffectiveness threshold can be overturned by considerations drawn from public social or ethical values and by the considerations implicit in nices developing case law the cumulative set of decisions that the institute has made over time in section 3 we set out the notion of reasonableness against which we aim to evaluate nice its relevancy as a standard of evaluation in this domain and why at a basic level it would be unreasonable for health systems not to have at least some body that sets priorities for healthcare coverage based on publicly justifiable principles in section 4 we then show that as well as it being generally reasonable that some body is instructed to set priorities for healthcare coverage nices method of prioritizing treatments for coverageits rebuttable presumption to fund interventions below a given threshold of cost effectivenessis also reasonable this argument shows that nices overall approach to prioritization decisions is reasonable however we also note its specifics are more questionable in the last section we question three aspects of nices approach its choice of the costeffectiveness threshold and the rationale for that choice its process of choosing certain social or ethical values as grounds for departing from that threshold and the way it adjusts that threshold in light of those social and ethical values nices approach to priority setting the presumption of cost effectiveness nice is responsible for a variety of functions within the english nhs clustered around the production of guidance 1 the core elements of nices work though are its technology assessmentsthat is its guidance to nhs purchasers on whether a given intervention constitutes a good buy in theory if not in practice these technology appraisals potentially have a profound impact on the range of services and treatments the nhs provides if an intervention passes nices evaluation process then it is recommended for use within the nhs and those commissioning services have an obligation to make them accessible to the populations whom they serve if the intervention is not recommended nhs purchasers are still free to fund that intervention if they so wish but they are not obliged to do so in the first instance nices appraisal agenda is set by the department of health however the institute also has a significant autonomy in deciding exactly how the issues for any one appraisal are determined and it operates with expert panels for appraisals that it constitutes and convenes once the initial choice of technologies has been made nice undertakes a scoping process to determine the appropriateness of the proposed remit and defines the specific questions that each technology appraisal will address next there is an assessment process wherein an independent academic group is tasked with a systematic evaluation of the relevant evidence available on a technology either from published data or the submission of a report from industry finally there is an appraisal process in which an appraisal committee considers evidence contained in the reports and analyses produced in the assessment phase and additional information supplied by consultees commentators clinical specialists patient experts and commissioning experts in addition nices citizens council provides a regular review of values for use in the appraisal of new technologies in the context of these procedures nice uses a decision protocol prioritizing costeffectiveness data nices assessment of cost effectiveness contains the following elements 1 evaluation of effectiveness nice seeks to identify the benefits arising from a healthcare intervention the benefit is defined as the average improvement in the health status of individuals receiving the intervention over and above any other gain they might receive the key measure of this benefit is the gain in qualityadjusted life years that a typical individual derives from an intervention health benefit is therefore measured by reference to both an extension of life and an improvement in the quality of life 2 evaluation of cost in the case of technology appraisals costs are total nhs and personal social service costs for medicines and devices costs are given by the published list price in recent years there has been some modification of this arrangement in the case of patient access schemes negotiated between industry and the doh these are innovative pricing agreements designed to improve cost 1 these include clinical guidelines which advise on the appropriate treatment and care of patients with specific diseases and conditions guidance on interventional procedures which detail the safety and efficacy of any surgery test or treatment that involves entering the body and guidance on public health activities ie those that aim to promote a healthy lifestyle and prevent ill health effectiveness and facilitate patient access to specific drugs or other technologies however such schemes are usually initiated when draft guidance from nice suggests that the intervention is not costeffective 3 evaluation of cost effectiveness nice evaluates an intervention by reference to its incremental costeffectiveness ratio nice defines the icer as the ratio of the difference in the mean costs of an intervention compared to the next best alternative to the differences in the mean health outcomes although nice has explicitly denied having a maximum value of an icer above which it does not recommend an intervention based on its decisions to date commentators have surmised that its normal threshold cost per qaly gained is between £20000 and £30000 it is sometimes claimed that nices use of costeffectiveness data in evaluating healthcare technologies equates to a maximizing strategy indeed nice itself might be said to encourage such a reading for example in its document on social value judgements nice states that it incorporates a maximizing approach into its work as an expression of a utilitarian approach to securing justice in the distribution of healthcare resources similarly alan williams an influential figure in the establishment of niceargued that technology assessments were driven by the objective of maximizing population health subject to a budget constraint however even if nices privileging of costeffectiveness data could be understood to follow from a nonwelfarist or extra welfarist normative position its actual use of such data does not equate to a maximizing approach first nice does not maximize qalys in the nhs because it makes no effort to identify and prioritise those interventions that offer the least cost per qaly gain out of all those interventions that might be funded say drawing up a league table of all relevant interventions and setting them in some order of priority much like the first stage of the oregon healthcare plan instead nice assesses technologies one by one making piecemeal judgements about whether a particular intervention meets its threshold degree of cost effectiveness irrespective of whether that intervention offers the least cost per qaly gain of all those interventions that might be funded nices decision rule here might be seen as analogous to disney worlds height restrictions to ride the big thunder mountain railroad disney world requires passengers must be at least 40 inches tall however this requirement does not mean the height of passengers will be maximized given the pool of prospective riders instead entrants are required to meet a specified minimum nice also only judges the cost effectiveness of those interventions it assesses compared to the next best alternative in other words a new treatment will be funded if the health gain that it provides relative to the existing standard treatment comes in at below the threshold cost again this fails to equate to a maximizing strategy for where the existing standard treatment is of low cost effectiveness the new treatment may be incrementally costeffective even it would be of low cost effectiveness in absolute terms here it might be argued that while each choice nice makes may not be optimally maximizing the cumulative effect of its piecemeal decisions over time will lead to a defined set of interventions with the highest valuefor example as measured by aggregate health gain for a given budget however for this to be true the target of its evaluationsthat is costs and benefits of the services and treatments under scrutinywould need to remain constant over the course of the decisionmaking process needless to say this is simply not reflective of the context in which nices evaluations are made in reality each assessment requires substantial information gathering and processing and during that time new technologies are developed the benefits package is in this sense a moving target in this way then a synoptic view of policy agendas is rendered practically impossible simply by virtue of the demands of information collection and processingsomething students of public policy have recognized since the pioneering work of simon on bounded rationality and braybrooke and lindbloms work on incrementalism in policy making rather than viewing nice as operating a kind of nonoptimum maximizing strategy then it is clearer to think of its process in terms of what simon called satisficing or satisfying of the minimum in this case ensuring that each recommended technology fulfils a minimum costeffectiveness threshold having established data on how far a given intervention satisfies its costeffectiveness threshold nice next recognizes a further set of social values as considerations that may justify recommending a technology whose icer puts it over that threshold as nice states in principle 3 of its social value judgments decisions about whether to recommend interventions should not be based on evidence of their relative costs and benefits alone nice must consider other factors when developing its guidance including the need to distribute health resources in the fairest way within society as a whole 2 nice adopts a twolevel process for assigning weight to social value judgments in its decisionmaking process at one level departure from an icer of over £20000 per qaly gained is considered acceptable on the basis of five considerations i the degree of certainty around the icer ii whether there are strong reasons to doubt whether the assessment of the change in healthrelated quality of life has been captured adequately iii the innovative nature of the technology iv whether the technology meets the criteria for special consideration as a lifeextending treatment at the end of life v aspects that relate to nonhealth objectives of the nhs nice takes each of these modifiers then to offer a potential justification for departing from its threshold of cost effectiveness where appraisal committees need to make an increasingly stronger case for recommending the intervention as the icer climbs over £20000 per qaly although nice has never issued specific instruction to appraisal committees with regard to the upper limit of the additional weight they should attach to the health benefits achieved by technologies in light of such considerations in practice the cumulative weight in circumstances where all modifiers apply has not exceeded 25 from a starting point of £20000 per qaly as well as those values specified as grounds for exceeding the icer nice also uses a set of further social and ethical values outlined in its key document social value judgements some of these follow from nices institutional context for example under uk law nice has an obligation to avoid discrimination so that factors like race or ethnicity age sex or gender and sexual orientation are to be considered as relevant only if clear evidence shows them to be proxies for clinical effectiveness however nice also includes other values taken to be widely held in uk society including amongst others special consideration of the needs of disabled people special consideration of the relief of stigma and reducing health inequalities while recognizing these values however nice either explicitly rejects or simply ignores others precisely where and how those values that nice includes within its decisionmaking process enter into its evaluation of a given technology is not always clear however the influence of such values in justifying departures from a strict accounting of a given technologys cost effectiveness is clear enough for example devlin and parkin show that cost effectiveness uncertainty and the burden of disease together explain nice decisions better than cost effectiveness alone moreover table 2 gives examples where nice has explicitly recognized certain values as influencing evaluations of particular technologies overall then how are we best to conceptualize nices process we propose that nices method is best thought of as setting a rebuttable presumption or default to prioritize the social value of cost effectiveness that can be modulated by other social or ethical values such as reducing health inequalities it is the reasonableness of nices method understood in this sense that we seek to evaluate in the next three sections reasonableness and priority setting in evaluating the very idea of a prioritysetting institution like nice we draw on a concept of reasonableness inherited from the philosophical literature namely rawls conception of reasonableness as the willingness to propose fair terms of cooperation and abide by them one important feature of this concept is that it allows for an allocation of resources that is reasonable and yet at the same time is based on a set of reasons about which reasonable people might disagree a disagreement is reasonable when it is possible for reasonable and wellinformed individuals to continue to disagree about the topic despite all the evidence and arguments that can be brought to bear on both sides a key contemporary source for this view is rawls discussion of the burdens of judgement according to which the complexity of empirical and normative assessment and the way in which conflicting considerations can be balanced mean that reasonable people will disagree overall then the actions of a prioritysetting body might be said to be reasonable to the extent that they appeal to reasons accepted as relevant by people who are trying to find ways of cooperating with each other on mutually acceptable terms and unreasonable to the extent that they do not appeal to reasons accepted as relevant moreover the actions of a prioritysetting body might still be considered reasonable even if they ultimately rest on matters about which reasonable people might disagree why think that it is important whether an institution such as nice meets the criterion of reasonableness that is why should it matter ethically speaking whether nice is reasonable or not in our view the moral significance of how far nice is able to meet the reasonableness standard arises from its being an institutional element in the attempt to secure universal access to medical care as is the case in the overwhelming majority of modern health systems in highincome countries the uk secures universal access to health care by operating a system of shared savings such a system spreads the financial risks associated with healthcare costs widely among those living in the country through systems of prepayment two features of this model are relevant for the reasonableness of institutions such as nice first in taxfunded systems like those of the uk spending on health care is in direct competition with spending on other politically determined goals for example education transport or security second the fixed budgets of these systems are insufficient to cover all conceivable and technically possible health needs to begin with new therapies can be expensive per unit cost for example novo seven a recombinant therapy for haemophilia resistant to firstline treatment costs €6000 per dose with doses needing to be administered every two hours until bleeding stops a protocol that in one german case led to total costs of over 2m for one patient moreover even where unit costs are low the widespread use of interventions that by themselves are relatively modest in cost can lead to considerable expenditure for example the nhs in the uk spent £3217 million on atorvastatin in 2009 though its unit costs in 2005 ranged from £035 to £064 per patient per day by virtue of the economic constraints in which it occurs then healthcare expenditure within a system of shared savings automatically invokes the ethics of opportunity costs given that money spent on one set of interventions will inevitably displace resources devoted to other interventions public authorities need to evaluate the opportunity costs involved in funding one set of healthcare intervention over others unless a positive decision to spend on one form of treatment is set against the forgone opportunity of the same resources going to other forms of treatment there is a risk of unfairness in the allocation in particular those most able to articulate their case may well be disproportionately favoured at the expense of those less articulate for this reason any body tasked with making decisions as to how resources are allocated is under a general duty to act reasonably that is at a minimum bodies such as nice must provide a rationale that makes clear how the social and ethical values and processes involved in such priority setting are acceptable to those seeking fair terms of cooperation this requirement might be thought of as both a moral requirement and an obligation arising from the social contract upon which many publicly funded healthcare systems are built drawing on the discussion of reasonableness earlier we can make three important points about the allocation of healthcare resources first a scheme of shared savings in health care can be reasonable even when it entails that some interventions will not be funded perhaps the least contentious case of a reasonable refusal to fund a particular treatment is when funding it would displace a greater number of more effective treatmentsas when a therapy is of high cost but only marginal effectiveness second there can be reasonable disagreement about the social values and processes to be used in prioritizing health care third we might also say that any attempt to contain costs for health care by setting explicit priorities will require a body that is similar to nice such bodies may invoke different values but in all cases there will need to be explicit appeal to publiclyheld social values to justifiable processes and there will need to be a body to make choices institutions like nice therefore meet a general criterion of reasonableness in that they should be considered reasonable by people who are willing to propose fair terms of cooperation and abide by them provided that others do in this sense institutions like nice reflect a duty of reciprocity among the beneficiaries of a scheme of shared savings those who benefit from scheme of mutual advantage have an obligation to restrain their demands where this is required for the viability of that scheme given this it is not surprizing to find that many countries now have institutions like nice that conduct various forms of health technology assessment and healthcare priority setting rather perhaps what is more surprizing is that certain countries have been known to deny the need for such bodies altogether indeed it is a natural outcome of the analysis thus far that while there might be room for reasonable disagreement about some of the particular social or ethical values and the processes that nice uses it does not look like there is much room for reasonable disagreement that a system of shared savings in health will require some kind of prioritysetting body for health care in fact alternatives seem unreasonable that is the only alternatives to authorizing a body to set priorities would appear to be unconstrained expansion of the healthcare budget or forms of implicit rationing neither approach is reasonable society is best served if it has institutions and agencies in which the terms of the social contract for shared health savings can be clarified and openly debated it is difficult to deny then that it is reasonable to have a body that performs healthcare prioritization in a system of shared savings but it does not yet follow from this that the particular values and processes through which nice has attempted to deal with these problems are reasonable it is to this matter that we turn in the next two sections the reasonableness of nices approach as seen in section 2 nice uses cost effectiveness as a filter a cost per qaly of less than the threshold amount will nearly always be sufficient to guarantee that the medical technology is approved above the threshold a technology will be approved if there are social and ethical values that give sufficient reason to overturn the default assumption there are two fundamental ways then in which the reasonableness of nices methods need to be justified a the reasonableness of having a costeffectiveness threshold that functions as a default and b the reasonableness of departing from that default on the basis of a given set of social and ethical values we turn to related matters such as the justifiability of nices actual choice of costeffectiveness threshold in section 5 a the reasonableness of nices use of a costeffectiveness threshold as a default the main justification for nices focus on cost effectiveness again derives from the ethics of opportunity costs section 3 explained how attention to opportunity costs is required in order to protect a system of shared savings given that money spent on one set of interventions inevitably displaces resources devoted to other interventions public authorities need to evaluate the opportunity costs involved in funding one set of healthcare interventions over other within such a protocol nices attention to cost effectiveness is rendered as an implicit value judgment on the acceptability of certain displacements over others that is to be considered acceptable those technologies that displace existing services must be able to secure a certain level of health benefit relative to those services it displaces the recognition of this logic is explicitly recognized by nice when it states that those developing clinical guidelines technology appraisals or public health guidance must take into account the relative costs and benefits of interventions when deciding whether or not to recommend them such logic might also be seen to follow ronald dworkin who once argued that it would be a disservice to justice for some citizens to expect others to contribute to costineffective care under resource constraints that is to say care that only marginally extends life of relatively poor quality again there may be disagreement about whether nices privileging of certain technologies on the basis of their ability to secure a certain level of health benefit over those that do not is the most important concern in questions of healthcare justice however to the extent that such disagreement exists it looks like reasonable disagreement in the sense we have described that is a disagreement that persists even amongst reasonable and well informed individuals despite all the evidence and arguments that can be brought to bear on both sides in this sense then while commentators might question whether nices use of a costeffectiveness threshold as a default represents the optimum strategy in prioritysetting dilemmas they would be hard pressed to argue that such a strategy is unreasonable b the reasonableness of departing from the default on the basis of a given set of social values as set out in section 2 although nices method gives primacy to cost effectiveness it does not make decisions solely on whether a given intervention passes its threshold rather it recognizes that other social or ethical values act as constraints on prioritizing cost effectiveness and that these values can justify exceeding the general cost per qaly threshold again this is eminently reasonable if nices focus on cost effectiveness reflects a shared interest in the prudent use of resources it is important that that interest is also framed by sensitivity to other claims that individuals have as a matter of justice to the benefits of shared savings for health care over and above cost effectiveness an integral element in the rawlsian conception of reasonableness is that any social institution is limited in the values that it can admit any policy paradigm like the default satisficing strategy of nice will therefore bias decision making to some values and not others a possibility that can be empirically demonstrated if the costeffectiveness threshold were not capable of being overturned by other considerations so that only the prudential interest in costworthy health care were recognized then nice would in effect be making a closed world assumption it would be saying that its basic principles covered all possible cases however a rebuttable presumption has a distinct logic from a closed world assumption because the presumption is defeasible rather than assuming that justified prioritysetting is logically deducible from a fully adequate set of principles nices modifiers allow for a broad and open range of considerations to be advanced so preserving the reasonableness of its decisionmaking protocols it is for the same reason that nices modifiers are preferable to numerically weighted qalys given that they preserve the exercise of judgment within the realm of reasonable disagreement areas for improvement we have argued that the general structure of nices methodits setting of a presumption to prioritize cost effectiveness that is rebuttable in light of certain social or ethical valuesis reasonable but to say that this general structure is reasonable is not to say that the structure or the particular way in which nice applies it cannot be improved in the following we outline three areas in which nices application of its method looks questionable we also argue that each of these might be seen as a problem of procedureof nice failing to make its reasoning transparentrather than of substanceof nice committing an error or making arbitrary decisions however absent proper explanation nice remains open to the charge that its actions are in some respects at least unreasonable a the costeffectiveness threshold the reasonableness of nices costeffectiveness threshold depends not just on the fact that it sets a costeffectiveness threshold but on the level at which that threshold is set and the rationale for setting it at this level as set out in section 2 despite nices explicit assertions to the contrary analysis of its decisions seems to imply that it currently operates a basic costeffectiveness threshold of around £20000 to £30000 per qaly gained although nice also remains silent on the rationale for this threshold other sources make clear that it is taken to be the mean cost of producing a qaly elsewhere in the healthcare system if £20000 to £30000 is the mean cost of producing a qaly within the nhs then this threshold looks reasonable within a fixed budget system funding a new treatment will have the implication that some activities currently being undertaken will have to be foregone if a new treatment is funded that costs more per qaly than the mean costs of producing a qaly then funding the new treatment will displace activities that would have created more qalys so unless there are social or ethical values that support funding the treatment despite its displacing a greater health benefit elsewhere it should not be funded however nices use of the £20000£30000 threshold looks questionable on a number of points first we might be generally suspicious of the thought that this particular threshold marks the mean cost of producing a qaly within the nhs simply on the basis that it does not appear to have been altered in nices lifetime even assuming that the threshold was set at the right level when nice began 15 years ago then it would be very surprizing if it were still at the right level now second recent research has suggested that there is good reason to doubt whether £20000£30000 is the mean cost of producing a qaly within the nhs claxton et al for example make a persuasive case that the cost to qaly in the wider nhs being £12936 per qaly gained meaning nices existing threshold is too high and that recommended interventions are displacing those purchasing greater numbers of qalys at equal or lower cost b nices choice of social or ethical values nices choice of certain social or ethical values as considerations with the power to overturn its costeffectiveness threshold might be considered a paradigmatic case of a set of judgments about which people reasonably disagree paraphrasing rawls it seems we might reasonably question nices choice of certain values as either relevant or irrelevant its formulation of those values as well as the relative weight it assigns to included values within its decisionmaking process however even if we recognise the outcome of these kinds of decisions as inherently contentious the way in which nice choses which values to include and which to exclude still needs to abide by requirements of good public reasoning in order to be considered reasonable that is nices choices still need to be made on the basis of reasons that are accepted as relevant by people who are trying to find ways of cooperating with each other on mutually acceptable terms the way in which nice seems to choose which social and ethical values might overturn its costeffectiveness threshold however remains confused and confusing in social value judgements for example nice sets out a range of reasons for rejecting a range of different social or ethical values but such rationales lack consistency and clarity the rule of rescue is rejected on normative grounds age as a proxy for social worth and personal responsibility are rejected because the citizens council said so rare conditions are excluded because they fall outside nices remit on occasion values are also rejected without explanation for example no explicit reason is given for why socioeconomic status should not be considered though it is explicitly ruled out to better defend the reasonableness of its choices nice needs a clear process for deciding on which social and ethical values can overturn its costeffectiveness threshold and which are deemed irrelevant most notably it needs to find a way of arbitrating between the different demands of ethical considerations procedural dictates and institutional directives c how nice uses social and ethical values in its decisionmaking process as we have argued nices use of modifiers is central to the reasonableness of its methods however in introducing such a logic of defeasibility nice potentially opens itself up to another charge namely that is specifies no explicit methods as to how the modifications are to be undertaken or what would be a maximal weight for individual values or all in tandem nices process of applying the social and ethical values outlined in its social value judgements is if anything less clear social value judgements explains that these values should be used by nice and its appraisal committees in designing the processes it uses to develop its guidance and in developing individual pieces of guidance however at no point does the document explain how such committees are supposed to employ the principles it outlines for example whether they are supposed to consider the impact of each and every value in each technology appraisal how the different demands of each value are supposed to be balanced against one another how they are supposed to relate to modifiers such as certainty and innovation and so on at one point social value judgements does instruct committees to include a statement of broad compliance with the principles it outlines and justify any departure from the principles it includes however this instruction tells committees only that they must not act against the social and ethical values detailed in the document not how to bring such principles to bear on the judgments they are making at this point of course it may be argued that no one has yet constructed an algorithmic method to balance various values against one another and that as such to criticise nice for failing to succeed on this score is to hold them to an unachievable ideal however although it is true that such a method is lacking various proxies are available not least arriving at a judgement through deliberation indeed it may be that this is the method that nice uses yet if nice relies on deliberation then it really needs to say so for without such an explanation nice leaves the way in which it uses social and ethical values open to criticism d a substantive issue or a process issue following from the last point it could be argued that all the criticisms levelled at nice above are open to an important counterargument namely that such criticisms mistake a problem of process for one of substance on this line of argument then it is not that nices methods either in their setting of the threshold choosing of social and ethical values or taking those social and ethical values into account in their decisions are themselves deficient rather it is just that nice has failed to adequately explain and articulate its various ways of working and rationales for the decisions it makes given that we are commenting on nices processes from the outside this possibility must be recognized however even if nices failure is only a failure to adequately communicate its processes that is still a significant criticism of its ways of working as commented in the introduction to this paper prioritysetting bodies such as nice may be evaluated not just on the principles they bring to bear in their decisionmaking processes but on the character of their processes in the latter category the most influential model of good practice here is afr which claims that prioritysetting bodies such as nice need to meet four conditions to be considered fair that decisions regarding coverage for new technologies and their rationales must be publicly accessible that these rationales must rest on evidence reasons and principles that all fairminded people can agree are relevant that there is a mechanism for challenge and dispute resolution regarding limitsetting decisions and that there is either voluntary or public regulation of the process to ensure that the first three conditions are met generally speaking nice fares well when measured against afrs four conditions of a fair decisionmaking procedure indeed nice has added several important procedural requirements missing from the original afr framework however if nice has failed to adequately communicate its processes around setting the threshold choosing social values or using social values to justify departures from the threshold it has also failed to abide by best practice described by afr namely by failing to make the rationales for its decisions publicly available conclusion step key aspects race ethnicity age as a proxy for social worth sex gender and sexual orientation socioeconomic status and social roles endoflife criteria 1 patients with life expectancy of 24 months 2 intervention offers life extension of 3 months compared to existing alternatives 3 intervention is licensed for small patient populations age may be invoked if 1 a good indicator of patients health status and or likelihood of adverse effects and or treatment response and 2 no practical way of identifying patients other than by age furthermore a lower discount rate for costs and benefits may be applied if a treatment 1 restores full or near full health in patients who would otherwise die or have a very severely impaired life and 2 the resulting health benefits are longterm

health systems that aim to secure universal patient access through a scheme of prepaymentswhether through taxes social insurance or a combination of the twoneed to make decisions on the scope of coverage that they guarantee such tasks often falling to a prioritysetting agency this article analyzes the decisionmaking processes at one such agency in particularthe uks national institute for health and care excellence nice and appraises their ethical justifiability in particular we consider the extent to which nices model can be justified on the basis of rawlss conception of reasonableness this test shares certain features with the wellknown accountability for reasonableness afr model but also offers an alternative to it being concerned with how far the values used by prioritysetting agencies such as nice meet substantive conditions of reasonableness irrespective of their procedural virtues we find that while there are areas in which nices processes may be improved nices overall approach to evaluating health technologies and setting priorities for healthcare coverage is a reasonable one making it an exemplar for other healthcare systems facing similar coverage dilemmas in so doing we offer both a framework for analysing the ethical justifiability of nices processes and one that might be used to evaluate others

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introduction control of infectious diseases often requires identifying persons who have been exposed to or contracted the disease and then placing restrictions on their behavior isolation of active cases and quarantine of persons who have been exposed are two examples of such identification and behavioral restrictions while such identification and restrictions may be critical for controlling the disease they may also lead to stigmatization of persons with the disease and social groups associated with the disease a critical distinction between good public health practice and stigmatization is that in good public health practice the persons undergoing behavioral restrictions are treated with dignity respect and support while in stigmatization persons are often treated with hostility and contempt a second critical distinction is the public health behavioral restrictions are evidencebased while stigmatization is often based in exaggerated fears and preexisting negative attitudes towards specific social groups stigmatization can cause substantial psychological social physical and economic harm to individuals and groups that are stigmatized 1 2 3 stigmatization may also lead to avoiding medical care attempting to hide disease and exposures and to hiding membership in groups associated with the disease all of which may contribute to further transmission 4 the negative consequences of infectious disease related stigmatization may be particularly likely if the stigmatization reinforces existing negative social stereotypes of the groups associated with the disease 56 early in the sarscov2covid19 epidemic there was considerable stigmatization of persons with covid19 and persons of chinese descent 7 some political leaders in the united states linked the sarscov2 virus to china through the use of derogatory terms such as china virus wuhan virus and kung flu 8 this terminology clearly linked the disease to persons of chinese nationality and the linkage occurred in parallel with an over 150 increase in antiasian hate crimes reported in the us in 20202021 compared to the previous year and reports of asians experiencing direct and indirect racial hostility 9 10 11 other countries have also reported antichineseantiasian sentiment associated with covid19 examples including australia 12 europe 13 and south korea 14 highly effective vaccines that greatly reduce serious illness and deaths from covid19 have been developed and made widely available in the us approximately 62 of adults in the us had received at least one dose of a vaccine by the time of our second data collection and 776 had received at least one dose as of may 3 2022 a year later 15 the development and partial implementation of the vaccines however has been followed by intense controversy 16 17 18 19 the controversy has often been fed by the considerable contains personal health information which is protected under the health insurance portability and accountability act such as vaccination status and whether the individual suffers from any of the underlying conditions that would be likely to make a covid infection more severe as well as demographic characteristics providing public access to the data used in our analyses could threaten loss of the confidentiality of phi and was not to be permitted according to our proposal submitted to the irb access to the data can be provided through an approved data use agreement between our institution and the institution with which the user is affiliated persons wanting to access the data should communicate with the nyu irb to initiate a data use agreement amount of misinformation and disinformation about covid19 that has been disseminated in the us often through social media platforms 20 21 22 23 in this study we used nonrandom national internet samples to compare the covid19 stigmatization us at two different points in the epidemic the first survey was conducted in august 2020 when various lockdowns had been implemented 24 the second survey occurred in may 2021 a time when approximately half of us adults had received at least one dose of a covid19 vaccine and the centers for disease control and prevention had just announced guidance that fully vaccinated persons no longer needed to wear masks in most settings 25 this time period also coincided with increasing public polarization over the vaccines 2627 we consider two primary questions in the comparison of the two surveys 1 did the overall frequency of stigmatization change and 2 did the factors associated with expressing stigmatization remain the same or change identifying changes and consistencies in stigmatization within a rapidly changing pandemic may provide insights into the nature of diseaserelated stigmatization and possibly for preparing for future epidemics and pandemics the health belief model is used to interpret the findings 2829 this model is frequently used in health communications in which the perceived threat of the disease is emphasized as a rationale for engaging in protective behaviors the protective behaviors may include avoiding contact with and placing behavioral restrictions on persons with the disease however given the controversies around the vaccines and the misand disinformation about the vaccines we did not attempt to use the hbm to predict how stigmatization and how the correlates of stigmatization might have changed from preto post development of the vaccines methods data collection amazons mechanical turk is a crowdsourcing platform that provides access to an ondemand and diverse global workforce an estimated 225000 of which are usbased 30 through mturk researchers and other requesters can post tasks that workers can complete if they meet prespecified criteria participants in this study were eligible to complete the online survey if they were at least 18 years of age had previously completed at least 500 mturk tasks and had approval ratings greater than or equal to 90 for previously completed mturk tasks the first survey was launched on august 5 2020 during a period of intense lockdowns and social distancing the second survey was launched on may 21 2021 soon after the cdc announced new guidance that fully vaccinated persons no longer needed to wear masks or practice social distancing outdoors or in most indoor settings excluding health care facilities while flying or taking public transit and in congregate settings 25 persons who had not been vaccinated however were still advised to wear masks in almost all situations outside of private homes the may 2021 survey included all the items in the august 2020 survey and additional items about having been vaccinated and intentions to become vaccinated data quality was assessed using two attention checks requiring participants to select a specific response option and a timetocompletion analysis given the significant outliers we implemented a minimum acceptable time to complete the survey of one standard deviation below the whole sample mean and a maximum cutoff score of 1000 seconds for the august 2020 survey and 1400 seconds for the may 2021 survey of the 1606 respondents between the two surveys a final sample of 1312 was retained for this analysis entries were excluded due to failed attention checks unacceptable completion times and having incomplete data study variables as a primary purpose of the 2021 survey was to compare covid19 related stigmatization at two points in the pandemicduring initial lockdown vs after vaccine rolloutwe used many of the items from the 2020 survey in the 2021 survey table 1 presents the major covid19 related items in our two surveys primary outcome the primary outcome of interest was covid19 related stigmatization measured with the stigmatizing attitudes and behavioral restrictions scale this sabr scale was adapted from a 2003 study comparing stigmatization of sars1 and hivaids 31 despite the many differences in the epidemiology of sars1 and hivaids there were strong similarities in the patterns of responses to the sabr items for sars1 and hivaids responses to all of the individual sabr items were significantly correlated across the two diseases and many of the same factors were associated with stigmatizing both sars1 and hivaids these associated factors included education income raceethnicity greater worry about contracting the disease less knowledge of the disease and mental health problems 31 exploratory factor analysis of the august 2020 survey showed a strong single general factor explaining approximately 71 of the variance with all items loading 06 or greater onto this factor reliability for this scale was excellent this sabr scale should be considered as measuring the intersection of stigmatization of covid19 and stigmatization of persons of chinese descent it was not intended to capture all aspects of stigmatization of either the disease or of the social group contact with persons with or associated with covid19 and with chinese persons these items were adapted from stigma research 32 suggesting that personal contact would decrease stigmatization experiences of discrimination related to covid19 and raceethnicity we included questions on having experienced stigmatization to examine whether experiencing stigmatization might lead to empathy for persons associated with covid19 and less stigmatizing or might lead to resentment and increased stigmatizing other covid19 related questions several additional questions were adapted from health belief model 2829 theory and the 2003 study that suggested the threat value of the disease will be associated with efforts to avoid contact probable depression was also considered likely to increase the threat value of the disease knowledge about the disease is clearly an important aspect of beliefs about the disease and our 2020 survey found that selfassessed knowledge was associated with reduced stigmatization new items were added on having underlying conditions that would increase the likelihood of severe covid19 illness and contact with persons who had severe covid19 as we hypothesized these would increase the perceived severity of the covid19 the vaccination behavior and intentions items were added to the may 2021 survey to examine the relationship of being vaccinatednot being vaccinated to stigmatizing preferred news source these items were used in the 2020 survey and were strongly associated with stigmatization in that survey that preferred news sources are associated with beliefs about covid19 has been noted in many previous studies 36 37 38 lack of hypotheses we did not formulate hypotheses for our two major research questions because we believed that the amount of polarization misand disinformation about the vaccines precluded straightforward application of any theoretical framework statistical analysis cross tabulations and chi square tests assessed bivariate relationships between the august 2020 and may 2021 surveys and demographic characteristics vulnerabilities to and experiences with covid19 and the sabr scale with pvalues of less than 005 used to detect statistically significant differences we calculated crude odds ratios to examine associations of possible predictor variables with the covid19 sabr items using univariate logistic regression all predictors and covariates were moved into multivariable logistic regression models to estimate adjusted odds ratios the vaccination statusvaccination intentions variable formed a continuum from positive to very negative attitudes toward vaccination and the cochranarmitage test for trend was used to assess relationships with covid19 related attitudes and experiences and the sabr items as noted below there were modest differences in the demographic characteristics of the respondents in the two surveys we thus used demographic characteristics as control variables in all multivariable analyses analyses were performed in stata version 17 39 the study was approved by the new york university institutional review board all participants provided written informed consent after reading a summary of the study but before beginning the survey results table 2 presents the demographic characteristics of respondents in the two surveys there were modest differences in the demographic characteristics of the participants in the two surveys participants in the may 2021 survey were moderately older less likely to be nonhispanic black or hispanic and less likely to have college degrees table 3 presents endorsements of the five sabr items in the two surveys in the may 2021 survey there was less endorsement of the sabr items including for the scale as a whole and for each of the individual items all the differences in the sabrs were in the direction of less stigmatization in the may 2021 survey the changes in stigmatization occurred within the context of changes in many other aspects of the covid19 pandemic table 4 presents information on experiences with and potential vulnerabilities to covid19 among the respondents there were multiple differences in the responses to these survey items participants in the may 2021 survey were less likely to be worried about contracting covid19 more likely to assess themselves as knowledgeable more likely to report contact with persons who had covid19 less likely to report probable depression and less likely to report social media as a source of information we then conducted a bivariable logistic regression of the odds of stigmatizing in the may 2021 survey compared to the odds of stigmatizing in the august 2020 survey the or was 045 we also conducted a multivariable logistic regression to control for the demographic and vulnerabilities and experiences variables in our survey the adjusted or was 052 showing that the reduction in endorsing sabr items remained significant after controlling for the other variables in our survey the odds for endorsing at least one sabr item were 48 lower in the may 2021 survey compared to the august 2020 survey factors associated with endorsing sabrs in august 2020 and may 2021 surveys we used logistic regression to identify factors associated with the sabr scale in the two surveys table 5 presents the bivariable and multivariable models for each of the two surveys overall there were many variables that were significant in at least one of the regressions and substantial similarities in the factors that were significantly associated with the sabr scale across the two surveys the variables significantly associated with stigmatization in both surveys were full time employment black race hispanic ethnicity worry about contracting received at least one inoculation by the time of the may 2021 data collection we therefore used our vaccination statusvaccination intentions variable for further analyses of the may 2021 survey data as shown in table 5 provaccine attitudes versus antivaccines were associated with endorsing stigmatization table 6 presents the sabr items by the vaccination statusintentions variable the sabr scale as a whole and all the individual sabr items showed significant differences across vaccination statusintentions the direction of the differences was consistent in that being vaccinated and having positive intentions to be vaccinated were associated with a greater likelihood of endorsing an individual sabr item the definitely will not get vaccinated group was distinctive in their low likelihood of endorsing any of the sabr items table 7 presents the relationships of the vaccination statusintention variable with selected covid19 experiences and vulnerabilities items that were associated with endorsingnot endorsing the sabr scale there were significant relationships between the vaccination status intentions variable and covid19 worry less knowledge having underlying conditions and contact with severe covid19 cases and probable depression discussion as noted in the introduction the primary purposes for the comparison of the preversus postvaccine development surveys were to assess 1 whether the frequency of endorsing covid19 related stigmatization changed and 2 whether the factors associated with endorsing covid19 related stigmatization changed reduction in stigmatization there was a substantial decrease in stigmatization both in the crude odds ratio and in the multivariable adjusted odds ratio this can be seen as a cause for some optimism with respect to decreasing covid19 related stigmatization in the us continuity in factors associated with endorsing stigmatizing attitudes the second major finding from the comparison of the 2020 and 2021 surveys were the multiple factors associated with stigmatization in both surveys these included full time employment black race hispanic ethnicity worry about contracting covid19 probable depression and fox news and social media as preferred sources of information and selfassessed knowledge about covid19 contact with chinese individuals and publicly funded news as preferred sources the health belief model and the sabr scale the health belief model posits that greater perceived threat of a diseasespecifically greater perceived severity and greater perceived susceptibilitywill lead to greater motivation to actions that would reduce the threat of the disease 29 endorsing behavioral restrictions on persons with or associated with a threatening disease would thus be a straightforward prediction from the model a number of the factors associated with stigmatization in table 4 are consistent with the hbm for example worry about contracting covid19 and having underlying conditions that would increase the likelihood of severe disease were positively associated with stigmatizing greater perceived knowledge about covid19 and more experience with covid19 were negatively associated with stigmatizing the changes between the two surveys were also generally consistent with the hbm for example worry decreased between the surveys and stigmatization also decreased vaccination behaviors and intentions the biggest change across the two surveys was the emergence of vaccination behavior and new attitudes towards vaccination at the time of the second survey being vaccinated or intending to be vaccinated was positively associated with endorsing stigmatizing attitudes and behavioral restrictions at first this may appear counterintuitive public health officials might have hoped that being vaccinated would greatly allay worries about contracting covid19 there are multiple possible reasons for the finding first our data should not be interpreted as showing an effect that vaccination did not reduce stigmatization we did not have data from the same individuals prior to and after vaccination so that we cannot infer causation at the individual level the prevalence of stigmatization among all respondents in the 2020 survey was 660 and the prevalence of stigmatization among respondents in the 2021 survey was 464 thus there was a net reduction of approximately 20 in survey participants endorsing stigmatizing attitudes and behavioral restrictions between the 2020 and 2021 surveys in the 2021 survey 557812 of the participants were vaccinated it is possible that the 20 reduction in the prevalence of stigmatizing all came from the 31 of 2021 participants who were not vaccinated but it would seem more likely that there was also a net reduction in endorsing stigmatization among the 2021 participants who were vaccinated second there are several plausible reasons for why those had been vaccinated might still have been quite concerned about contracting covid19 at the time of the second survey the vaccines were never presented as completely effective at the time the second survey the cdc was still recommending that vaccinated persons wear masks in many public settings 25 also the vaccinated persons did have higher prevalence of underlying conditions more personal experience with severe cases of covid19 and less selfperceived knowledge about covid19 all of which could contribute to the threat value of covid19 and lead to endorsing stigma and behavioral restrictions even if one was vaccinated third as part of the increasing polarization over the vaccines there were increasing news stories raising doubts about the effectiveness of the vaccines and concerns about the potential harmful side effects associated with being vaccinated which could have increased the perceived threat of covid19 among those who had been vaccinated 40 each of these factors would be consistent with the basic premise of the health belief model that greater perceived threat of covid19 would be likely to motivate endorsing stigmatizing attitudes and behavioral restrictions on persons who associated with covid19 news sources there has been varying coverage of covid19 among different news sources in the us with some sources taking an approach based on science while others have taken a more xenophobic and antiscientific approach specific news sources particularly fox news significantly downplayed the covid19 pandemic particularly in the early stages and were skeptical of much of the scientific expertise surrounding the virus and transmission of covid19 4142 however fox news also spread many xenophobic messages about covid19 fox news frequently referred to covid19 as the chinese coronavirus which acted to reinforce the negative stereotypes of asian americans for examples fox news carried stories that the chinese government intentionally released the covid19 virus 43 44 45 these xenophobic stories likely contributed to some of the associations seen in the analysis related to chinese individuals while fox news did downplay the importance of covid19 as a disease which would be associated with lower stigmatization of persons associated with the disease fox news also emphasized the association of covid19 with china which would have increased stigmatization of chinese persons in our sample the xenophobic antichinese effect appears to have been much stronger that the downplay of covid19 effect potential causal pathways many of the odds ratios in the univariable logistic regressions were attenuated in the multivariable regression models suggesting complex associations with many variables having both direct and indirect associations with endorsing stigmatizing attitudes and behavioral restrictions having longitudinal individuallevel data would be useful in developing a full conceptual model of causal pathways for endorsing stigmatizing attitudes and behavioral restrictions ideally individuallevel data would be matched with significant developments in the pandemic initial concern and lockdowns development of vaccines political polarization of vaccination and mask mandates emergence of multiple variants and emergence of pandemic fatigue the sabr scale the sabr scale was originally developed for studying stigmatization of sars1 and aids these were serious diseases the case fatality rate for sars1 was about 14 46 and until the development of the cocktail antiretroviral treatments for aids its case fatality rate was over 90 47 hiv infection was lifelong at the time we first used the scale for covid19 august 2020 the case fatality rate was unknown but the numbers of covid19 deaths in the us were quite high approximately 450500 per day 48 we are currently updating the sabr scale to increase its applicability to less serious infectious diseases such as covid19 which now has a very low case fatality rate the data in this report provide evidence for multiple aspects of construct validity for the scale higher worry about contracting covid19 was associated with greater likelihood of endorsing stigmatizing attitudes and behavioral restrictions on persons with or associated with covid19 which may be considered construct validity for attitudes the scale also had construct validity for experiences with previous exposure to severe cases of covid19 and having underlying conditions associated with greater endorsement of stigmatizing attitudes and behavioral restrictions the scale also had construct validity for behavioras deciding that one would definitely not get vaccinated can be considered behaviorand was associated with very low sabr scale scores the scale also showed construct validity with stigmatization theory 14 as greater contact with persons of chinese descent as associated with less endorsement of stigmatization and behavioral restrictions of persons of chinese descent this short scale cannot be considered as a comprehensive measure of the stigmatization of an infectious disease associated with a socially devalued group but there is substantial evidence for its construct validity future research while many of the relationships in our data are generally consistent with the health belief model we would not propose that this model can generate a full understanding of the causal pathways leading to stigmatization of covid19 as noted in the introduction covid19 stigmatization was added to existing antiasianantichinese stigmatization in the us and was followed by a large increase in antiasian hate crimes 9 we conceived of our scale as measuring the intersection of antichinese stigmatization and anticovid19 stigmatization and not to measure separate components future research should involve adapting the scale to changes in knowledge about covid19 for example it clearly has a much lower casefatality rate than sars1 or aids but there is also the potential for symptoms persisting over long periods of time 49 the scale also needs to be complemented with measures of factual knowledge of covid19 the sources of accurate misand disinformation and of group affiliations and as noted above individual level longitudinal data tied to developments in the epidemiology psychology and politics of the pandemic are needed limitations several limitations of this study should be mentioned first we did not have a nationally representative sample in either survey we did however control for demographic characteristics in our multivariable analyses second we did not have the same respondents in both surveys so we were unable to study changes in attitudes and stigmatization at the individual level third we had only a single item measuring knowledge of covid19 and this was based on selfassessment we were not able to assess the factual content of the respondents selfassessed knowledge having an accurate assessment of the respondents knowledge of covid19 and of the vaccines might be quite important in assessing relationships between news sources and stigmatizing these limitations are important but we believe that our data do show an important reduction in endorsing stigmatizing attitudes and behavioral restrictions the general applicability of the health belief model and the importance of different media as preferred news sources the development and politicization of the vaccines has led to an additional layer of complexity in the stigmatization of persons who have covid19 and groups who are associated with covid19 conclusions there was a very substantial reduction in the endorsement of stigmatizing attitudes and behavioral restrictions between the august 2020 and may 2021 surveys many of the factors associated with stigmatizing were significant in both surveys the development and partial implementation of effective vaccines did not eliminate stigmatizing and added new complexity to the patterns of stigmatization generating enough public concern about a new threat to health to lead people to take appropriate actions while minimizing stigmatization of persons having or associated with the disease is always a difficult public health communication task achieving this balance may be especially difficult in a context of widespread misand disinformation a variety of competing news sources political polarization and the potential for hate crimes supporting information s1

to compare covid19 stigmatization at two pandemic time points 1 august 2020during lockdowns and prior to vaccine rollout and 2 may 2021during vaccine rollout when approximately half of us adults were vaccinatedcomparison of covid19related stigmatization and associated factors in two national internet surveys conducted in august 2020 n 517 and may 2021 n 812 factors associated with endorsing stigmatization were identified using regression analysis the main outcomes included endorsement of stigmatization and behavioral restrictions towards persons with covid19 and towards persons of chinese descent a previously developed stigmatizing attitudes and behavioral restrictions scale was adapted to measure the intersection of negative attitudes toward covid19 disease and negative attitudes toward persons of chinese descentcovid19 related stigmatization declined significantly from august 2020 to may 2021 many factors were associated with stigmatizing in both surveys full time employment black race hispanic ethnicity worry about contracting covid19 probable depression and fox news and social media as sources of information all positively associated and selfassessed knowledge about covid19 contact with chinese individuals and publicly

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larger structural environment including partners family and community member as well as policy makers funders and program implementers to work together for the common cause these consolidated efforts may not only lower the risk of psychological distress but has potential to create long lasting solutions to benefit the wider community background globally hiv disproportionately affects women compared to men 1 in uganda 8 of women are living with hiv compared to 6 of men 2 reasons for womens higher hiv burden relate to both physiological and sociostructural factors 3 4 5 6 in particular women face gender and power inequity economic vulnerability and dependence and genderbased violence which may limit options for negotiating intimate relationships and safer sex 5 7 8 9 10 many of the sociostructural factors that increase womens risk of hiv acquisition 47 11 12 13 14 15 16 17 18 also compromise linkage and retention in hiv care 19 20 21 22 23 24 25 such gaps have significant consequences for women living with hiv in terms of health quality of life and survival in addition to the risk of hiv transmission 24 26 27 28 29 30 31 32 for wlwh who become pregnant the stakes of engaging in hiv care are amplified given the risks of perinatal transmission 3334 in uganda where option b has been the standard of prevention of mother to child transmission programming since 2014 35 antenatal clinic hiv prevalence is 7 and in 2014 84 of pregnant wlwh were enrolled in option b and receiving hiv care 36 37 38 uptake of services to prevent perinatal hiv transmission is limited by many factors including limited information fear of unintended hiv disclosure lack of support from intimate partners perceived hiv and pregnancy stigma from the community and health care providers and womens concerns about health implications of longterm antiretroviral treatment 3940 as a result pregnant wlwh are less likely than nonpregnant wlwh to get tested for hiv access hiv care and initiate art 29 for many wlwh pregnancy and the postpartum periods introduce additional stressors related to individual partnership dynamics and community and healthcare expectations 41 42 43 44 although quantitative evidence suggests that the postpartum period in particular is associated with poorer adherence to art and higher rates of disengagement from hiv care 4143 45 46 47 there is limited understanding of the types of psychosocial challenges facing pregnant and postpartum wlwh particularly in rural settings where availability of hiv and mental health services may be more limited thus the goal of this study was to explore psychosocial challenges experienced by wlwh living in rural uganda during pregnancy and the postpartum materials and methods study setting we conducted this study in mbarara a rural town in southwestern uganda located approximately 270km from kampala the capital city mbarara town has an estimated population of 195013 people 48 adult hiv prevalence in the region is estimated at 8 and women carry a higher burden of infection with a reported prevalence of 9 compared to 7 in men 4950 all study participants were accessing care at a public hiv clinic within the regional referral hospital the clinic offers comprehensive hiv care including art free of charge to patients study participants and recruitment study participants were wlwh recruited from the uganda aids rural treatment outcomes cohort study 51 from 20052015 uarto followed over 700 adults men and women living with hiv who initiated art at study enrolment and who were receiving care at the local hiv clinic and living within 60 km of the clinic site data from these analyses comes from a qualitative substudy of the experiences of depression among wlwh during pregnancy and the postpartum period eligible participants for this substudy were females enrolled in the parent uarto cohort study and had experienced a pregnancy in the last two years prior to recruitment the primary aim was to explore experiences of depression among wlwh during pregnancy and postpartum we used purposive sampling to select eligible participants with a range of experiences based on their responses to the hopkins symptoms checklist within the parent cohort study the primary research objective was to explore womens experiences with depression during and after pregnancy because women were recruited from a cohort study where depressive symptoms were surveyed quarterly we took advantage of these data to capture a range of womens experiences with depressive symptoms cohort participants were screened for depression symptom severity using a modified version of the hscl15 for depression based on previous studies using hscl in uganda a 16th item was included feeling like i dont care about my health 52 each of the 16 symptoms is scored on a 4item likert scale ranging from not at all a little quite a bit to extremely and the total depression severity score was calculated as the mean of the 16 items with higher scores indicating greater depression symptom severity we considered a dichotomous measure of probable depression defined as an hscl16 score 175 which has been previously used as a positive screen for depression 52 53 54 55 56 57 we recruited 4 groups of womenthose with stably high scores those with stably low scores and those with rising and those with falling scores all during pregnancy and postpartum a trained research assistant contacted potential participants by phone and explained the purpose of the study the anticipated benefits and the risks of participating if interested the research assistant scheduled an interview at a location and time chosen by the participant the informed consent process took place on the interview day ensuring voluntary participation confidentiality and safety participants received transport reimbursement of approximately 5 usd as noted above the analyses presented here are related to an emergent theme of psychosocial challenges experienced by the participants data collection we conducted semistructured interviews with twenty participants from february through august 2014 we conducted one on one in depth interviews with participants according to guidelines outlined by pope and mays 58 the questions were designed to capture experiences of wlwh during the perinatal period and were developed through input from mental health care providers and experts in reproductive health hiv and safer conception practices the interview guide was piloted extensively among the study staff to assess its clarity and content and revised accordingly by removing some questions and rephrasing others interviews lasted approximately one hour the interview guide included questions about wlwhs experiences during pregnancy and the postpartum womens thoughts and feelings about becoming pregnant how their hiv status influenced their thoughts and feelings towards pregnancy and their partners thoughts towards the referent pregnancy the final section of the interview explored feelings and experiences of the participants following childbirth ugandan research assistants trained in qualitative research methods and fluent in english and the local language conducted the interviews and were blinded to participants quantitative depression scores and patterns ethical considerations all participants provided voluntary written informed consent at study enrollment the institutional review committee mbarara university of science and technology the partners human research committee massachusetts general hospital and the research ethics board of simon fraser university approved the study consistent with national guidelines we received clearance for conducting our study from the uganda national council for science and technology and from the research secretariat in the office of the president given the focus of the study we developed and implemented a protocol for referring distressed participants to a psychiatrist at the mental health clinic at the recruitment site at the beginning of the study a ugandan psychiatrist trained all research assistants to recognize signs and symptoms of depression if the research assistants noticed signs or symptoms of acute and severe distress they were instructed to refer the participant to the mental health clinic if the research assistants noticed that the participant needed counseling related to hiv care the research assistant referred the participant to the counselor in the hiv clinic two participants used our referral protocol over the course of the qualitative substudy data analysis demographic information for each participant was collected from the uarto cohort database we conducted oneonone in depth interviews with participants according to guidelines outlined by pope and mays 58 research assistants translated and transcribed audio recordings of the interviews into english transcripts were reviewed by research assistants and a psychiatrist to assess translation quality and fidelity nvivo 10 was used to facilitate analyses content analysis was used to conduct initial analysis of the data exploring the experiences of depression among wlwh during pregnancy and the postpartum according to strauss and corbin 59 transcripts were read by 9 research team members to identify major themes and to inform development of a coding scheme to categorize the data the final coding scheme included both a priori themes and those which emerged from preliminary readings of the transcripts the codebook guided the coding process which was completed by two members of the research team the two coders compared coding for four interviews to ensure coding reliability and to verify understanding of the codebook 60 and then coded the remaining interviews independently after coding all interviews the research team further discussed the emergent themes in the context of coding themes relating to psychosocial challenges experienced by wlwh emerged from the data as an independent theme and were explored through an iterative process using techniques described by miles and huberman 61 data were further organized into themes and sub themes relating to psychosocial challenges faced by wlwh during pregnancy and the postpartum 59 data reduction methods were employed to extract the overarching narrative from the most pertinent data results fortytwo participants were eligible to participate in the study and 20 participants were recruited we aimed to recruit a similar number of participants in each category however only 5 of 42 eligible participants had steadily high hscl scores participants had a median age of 33 years and 95 were virally suppressed at the uarto visit closest to the interview date women had a median of 3 living children and a median cd4 cell count of 677 cells mm 3 of the 20 women 18 had a live birth and 2 experienced other pregnancy outcomes challenges data from 20 interviews was summarized into 5 themes that emerged as major challenges faced by wlwh during pregnancy and the postpartum hivrelated stigma from health professionals hiv status disclosure dilemma unintended pregnancy and intimate partner violence hiv and environmental structural barriers distress and fear related to maternal and child health each of these challenges is discussed in detail below hiv related stigma from health professionals participants shared their experiences about hivrelated stigma during pregnancy and the postpartum which centered on shame associated with having children as a wlwh participants experienced stigma and discrimination whenever they went to hospital for antenatal care services wlwh were treated negatively by health care providers compared to hiv positive women in addition wlwh received negative messages about being pregnant while hivinfected from health workers to discourage them from reproducing as a result of the negative information and reception from health care professionals as wlwh sought care some women expressed personal shame around being hivinfected and pregnant sometimes when you get to the health facility and they look at your documents and they realize you are infected hiv they do not handle you as well as that one who is not infected it was as if it was a taboo to be sick hiv positive and then you get pregnant i was saying if i come here hiv clinic to get medicine and they see me pregnant will they not call me a fool you have hiv and you are pregnant some women received unexpected reactions from health workers after learning of their pregnancy instead of support women received criticism and blame from health workers for becoming pregnant and were openly discouraged from reproducing because of their hiv status hiv status disclosure dilemma although participants had a strong sense of obligation to disclose their hiv status they feared the negative reactions of disclosure including fear of abandonment and intimate partner violence women worried that disclosing their positive hiv status to their partners would lead to assumptions that they had been unfaithful to the partnership and they feared the emotional and physical violence that would follow despite this dilemma some women were brave enough to disclose although deep inside they expected the worst reaction from their partners i started thinking will i deliver this baby alive and wont the man himself kill me in fact i even first hid the papers hiv test results and kept quiet but later my heart told me tell him if he leaves me he leaves me so long as he takes care of the pregnancy he instead told me lets go to hospital and they tested us and told us that the man is negative but i was positive hiv positive i told him leave me alone you are negative i am positive and how are we going to live together he said its not possible to leave me i kept quiet and we stayed together in addition to the fear and distress about impending partner violence and abandonment following disclosure women also anticipated negative reactions associated with hiv within the community including gossip and discrimination to avoid this some women kept their hiv serostatus a secret what happens at our village you find people talking about you hiv positive women so and so is sick hiv positive but does a sick person look like this you see someone trying to ask you and know about your status but you keep quiet because when you tell them they spread it in the community by the time you got pregnant were you stupid after giving birth he started treating me badly he knew that he had finished me off because he had already infected me with hiv i no longer had anywhere to go he stopped me from working and stopped me from coming to hospital to pick my medications arvs hiv and environmental structural barriers structural barriers related to hiv and the environment complicated womens perinatal experience participants endured financial constraints and struggled to sustain themselves and the baby the stress of balancing work pregnancy and childcare as an hiv positive woman was hard to endure some of the women spent more time at work which interfered with the care their children received financial constraints limited the womens access to hiv care due to lack of transport fare to the hiv clinic compromising their physical health women described these situations as being stressful you see that stress never stopped there hiv and pregnancy i failed to stay with her child because of work i had her child for two months before i went back to work the third month i was fidgeting with her but i saw that she child needed to be attended to she would be in the house where the woman worked crying and everyone would be concerned i gave her child to my friend so i could continue working at times we wlwh meet financial problems for example when you are supposed to come and get more drugs arvs you find that you do not have money for transport you go to a friend to borrow money and you find that she does not have it so you exceed your appointment dates for a week or more and when you come to collect your drugs the doctors do not treat you well that also makes us feel bad additionally women experienced challenges associated with dependence on their partners to satisfy basic needs while navigating polygamy and multiple partnerships some participants reported their partners to be involved with other partners which complicated their relationships in addition to interfering with the stability of relationships polygamy and multiple partnerships compromised the financial support women received from their partners which in turn affected their physical health there is no good relationship with my partner because he has a second wife he does not look after me properly all the money goes to the other side second home he does not bring for me the good things food that i need to eat to sustain my health some participants struggled with cultural norms that deny women reproductive autonomy which prevented them from making decisions concerning having children and utilizing available contraception methods some women reported that pregnancy resulted from their partners and partners families wanting children rather than their own desire to have children even when women did not want to conceive they had to comply with and fulfil their partners desires after the first girl child i started family planning the injection for three months but eventually i stopped because my mother inlaw and fatherinlaw were accusing me that i gave birth to one child like an antelope significant distress and fear related maternal and child health the experience of pregnancy while living with hiv resulted in significant anxiety across several domains participants were distressed about the possibility of hiv transmission to their unborn babies and feared that their babies would die soon after birth due hiv i kept saying even if i deliver him will he live maybe he will fall sick from the womb because of my poor strength i would think now i dont have enough care life is deteriorating wont i deliver the baby and he just dies the distress and fear about the babies health were further fuelled by the womens own deteriorating health during pregnancy as women feared they would not be strong enough to work and provide for themselves and their children or that their children may end up as orphans i used to think that i am going to have this child and fail to get what resources to take care of him and he will eventually die i thought i would have no strength to educate him because i would be helpless and not be able to work for myself because of hiv i was also thinking that if i fall sick i will no longer be strong enough to work for him get food to feed him and he would eventually die the fear that their children would end up as orphans brought on many questions concerning the status of the children and how they would adhere to the medications without their mothers participants worried had distressing thoughts about how they take care of an hiv positive child knowing he would die but also worried about who would give appropriate care to the children if the mother dies this distress was persistent throughout the infant testing period i was so scared that now my baby is sick and if they tell me that he is sick what will i do i kept thinking now will i look after him put him in school knowing that he will die now what if i die and am buried who will ever look after him but even in the village at his grandmothers place how will he end up there he is already on medicine arvs who will bring him to the hiv clinic to get medicine i have not disclosed to my inlaws now if i die without disclosing that the child is sick who will pick his medicine arvs who will take him there hiv clinic i will die today and he child dies tomorrow women struggled with distressing thoughts about their young children taking arvs in case they were perinatally infected with hiv the thoughts centered on the ability of the children to tolerate the side effects of medications and the effects of the medications on childrens growth and development i was so bothered and suffering that i am going to have a child that is hiv positivewhat was i going to dofinding me at the pharmacy collecting drugs for myself and then for my child 26 discussion participants in this study described a myriad of challenges during pregnancy and the postpartum including experienced stigma discrimination and criticism from health workers community members and violence from partners associated with being pregnant as a wlwh while some of the participants were openly criticized by healthcare professionals for being pregnant others were worried about the reception at the health facility based on a personal belief that being pregnant while living with hiv was shameful women reported structural challenges including poverty and cultural norms that uphold men as the decision makers as factors that worsened hivrelated challenges during pregnancy physical violence and emotional and sexual abuse from intimate partners were common among study participants women also experienced stress anxiety and worry related to their own health the health and future of their babies and the risk of hiv transmission understanding these challenges can inform interventions to support wlwh to better navigate hiv care during pregnancy and postpartum adhere to pmtct recommendations and support their psychosocial needs to improve mental and physical health outcomes our study findings parallel with findings from a previous study in ethiopia whereby wlwh were threatened with withdrawal of their hiv care services if they became pregnant 62 similar to our finding reports of verbal abuse neglect by health care workers and social isolation within communities against pregnant wlwh have been documented 4 as a result some wlwh drop out of hiv care due to the stigma associated with hiv while others attempt to conceal their hiv status for fear of stigma discrimination and negative judgment within the community 47 63 64 65 hivrelated stigma prevents many pregnant wlwh from initiating and adhering to antiretroviral therapy 66 67 68 in order to realize positive benefits from the implementation of hiv prevention and treatment strategies including pmtct programs efforts to reduce hivrelated stigma in pregnancy must be prioritized 69 disclosure of hiv status was a major challenge among our study participants due to anticipated and real negative consequences especially from intimate partners our findings are in agreement with previous studies that have reported intimate partner violence blame and abandonment associated with disclosure of an hiv positive status among wlwh 2770 as a result many women refuse to test for hiv to avoid disclosure 7172 which limits their ability to engage and adhere to pmtct care 4766697374 other findings indicate that women experienced intimate partner violence in the form verbal physical emotional and sexual abuse this is consistent with findings of previous studies that intimate partner violence is commonly perpetrated against wlwh 75 76 77 in a study in south africa wlwh who conceived without discussing their pregnancy intentions with their partners experienced more violence from their partners than wlwh who did discuss their pregnancy intentions 78 violence against pregnant wlwh compromises physical and emotional wellbeing and interferes with engagement in hiv care and adherence to medications hence increasing the risk of perinatal hiv transmission 79 80 81 82 in addition to coping with hivrelated stigma hiv status disclosure and intimate partner violence these challenges were amplified by poverty and cultural norms which put women in a vulnerable position 891683 poverty and economic hardships often force wlwh to endure abusive or unhealthy relationships to retain economic support from their partner 84 women in this study reported experiencing distress fear and worry about their own health and the health of their babies and about being unable to provide for themselves and their children due to ill health anxiety and distress associated with hiv among women has been reported in previous studies 85 86 87 the experience of pregnancy and postpartum among wlwh has been characterized by negative emotions including fear anxiety guilt and sadness in previous research 8586 in our study we found that fear and distress among wlwh during the perinatal period centered around the health and status of the baby persisting throughout the infant hiv testing period which is consistent with findings from previous research 8889 our qualitative study had some limitations the study had a small sample size therefore the views of the participants may not represent the challenges of all wlwh during pregnancy and the postpartum we interviewed women who were enrolled in hiv care and part of a cohort study where they received regular reviews in the hiv clinic and other kinds of support including transport reimbursement and other incentives like cooking oil this could have resulted in reporting bias because most of these women were enrolled in care for over five years their experiences may be different from those women who are early in the hiv and pmtct treatment cascade conclusions efforts to eliminate perinatal transmission may not be successful until the psychosocial challenges experienced by wlwh along the treatment cascade are addressed women continue to experience stigma and discrimination fear of disclosure gender inequality intimate partner violence and economic hardship these challenges prevent women from testing for hiv and also impair their ability to adhere to medications which may compromise their physical health and the health of their children to enable wlwh to successfully navigate hiv care during pregnancy and the postpartum strategies aimed at encouraging hiv testing safe disclosure and involving male partners in antenatal care should be considered 24 creating opportunities to address intimate partner violence are likely to decrease the stress and negative consequences of disclosure and may enable many women to access hiv care services 14 efforts to promote gender equity and economically empower women will enable wlwh to make autonomous decisions concerning their health engage in care and adhere to pmtct treatment recommendations during pregnancy and the postpartum period 16 to help wlwh overcome the challenges that they grapple with community members partners health care providers and family members and larger structural environment including policy makers funders and program implementers should be involved and work together to empower communities in general through which wlwh can benefit 90 previous research has documented that partner and family and community support is instrumental in alleviating challenges faced by wlwh lowering the risk of psychological distress in this population 9091 interventions that seek to mitigate the effects of these stressors on wlwh particularly during the perinatal period may maximize the wellbeing of women and their children the psychosocial challenges that impair womens ability to engage in hiv care and adhere to arvs should be explored and subsequently addressed at community level to enable wlwh to navigate the hiv treatment cascade all relevant data are within the paper the interview guide is submitted as a supplementary material

the complexities of navigating pregnancy while living with hiv predispose women to additional stress finding ways to minimize psychosocial challenges during the perinatal period may maximize the wellbeing of mothers living with hiv and their children the goal of this study was to explore psychosocial challenges experienced by women living with hiv wlwh during pregnancy and the postpartum we conducted individual indepth interviews with 20 wlwh recruited from an hiv treatment cohort study in mbarara uganda as part of a larger study exploring perinatal depression we conducted content analyses to identify themes related to challenges of wlwh during pregnancy and the postpartum participants had a median age of 33 years iqr 2835 a median of 3 living children iqr 25 and 95 had achieved hivrna suppression challenges were organized around the following themes hiv related stigma from health professionals hiv status disclosure dilemma unintended pregnancy and intimate partner violence hiv and environmental structural barriers and distress and fear related to maternal and child health stigma centered on discrimination by health care professionals and personal shame associated with being pregnant as a wlwh this led to difficulty engaging in hiv care particularly when coupled with structural barriers such as lack of transportation to clinic participants experienced intimate partner violence and lacked support from their partners and family members distress and fear about the health and uncertainty about the future of the unborn baby due to maternal deteriorating physical health was common the perinatal period is a time of stress for wlwh challenges experienced by wlwh may compromise successful engagement in hiv care and may reduce quality of life for women and their children strategies aimed at alleviating the challenges of wlwh should involve the

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introduction everyday peace is a concept recently developed in the conflict and peace studies literature key scholars including ring mac ginty williams and others explore the idea as a means of explaining the everyday practices people enact to minimise conflict and harm in situations of communal and ethnic conflict this theory has been used to explain what occurs at the community level in conflicted regions including northern ireland south sudan uganda south africa pakistan india myanmar the philippines and colombia this framework was originally intended as a means of describing the observed behaviours of those living in intercommunal conflict settings and seeking nonviolent coexistence however emerging research is currently attempting to utilise everyday peace as a framework for working with conflictaffected people to explore ways that agency might be strengthened to promote local peacebuilding and peace formation this paper assesses the transferability of the theory developed in the context of intercommunal conflict to practices utilised by women experiencing intimate partner violence it analyses new narrative inquiry data from seven experienced family violence practitioners against the literature to consider whether women experiencing ipv adopt practices similar to those documented in the everyday peace literature it does this by systematically working through the major social practices identified by everyday peace theory and identifying whether these are similar to strategies adopted by women experiencing ipv practices identified in the everyday peace literature best correlate with what are termed placating strategies in the family violence literature ipv research suggests these comprise over 80 percent of the strategies adopted by women addressing violence however we argue that simply equating these strategies with placating narrows and diminishes their value making them appear weak compared with resistant and help seeking strategies we suggest the everyday peace framework may be helpful in rejecting soft reductionist conceptualisations of such practices reframing these responses as potentially considered deliberate acts implemented with strength and agency many papers have examined the strategies employed by women experiencing ipv and noted the constant strategic and conscientious performances acted out to protect themselves and their families this paper hones in on the most mundane and everyday of these to date the focus has been on more sensationalist actions with everyday strategies only briefly described in the literature these include staying out of the perpetrators way avoiding arguments obeying perpetrators orders and being quiet the current paper seeks to extend this literature by drawing on family violence practitioners experience to add more qualitative detail around socalled placating strategies arguing women implement these strategies with intent and courageous agency to help them survive protect their children and keep the family together in extremely complex and challenging situations using these strategies gives women time to build insight into cycles of violence and plan longerterm responses which may or may not include escape further in cases where the couple are no longer together everyday peace practices may illuminate strategies adopted to work toward positive peace whereby exintimate partners can cultivate functional nonintimate relationships notably this paper does not seek to evaluate the effectiveness of the strategies employed by women although this is an important area requiring further research the key contribution of the paper is to assess the utility of everyday peace as a framework for understanding certain actions women use to minimise harm and avoid conflict and potentially work towards positive peace in the process the paper lays a foundation for programming ideas aimed at recognition and strengthening agency the authors recognise that family violence comes in many forms including between parents and children siblings grandparents carers and same sex couples and that men can be victimssurvivors of ipv perpetrated by male or female partners however this paper focuses solely on ipv in which perpetrators are men and victimsurvivors are women this is deliberate due to the expertise of the practitioners participating in the empirical component and given the fact that the majority of ipv fits this pattern moreover we contend that using genderneutral language in the ipv space masks the predominant oppression of women through such violence and ignores the highly gendered nature of most ipv similarly as this paper examines the agency women exercise in very difficult circumstances the term victim disempowers and reinforces depictions of them being passive helpless and psychologically paralyzed further survivor suggests that the person has emerged from a difficult or dangerous situation while this paper is located within the heat of that situation thus while acknowledging the limitations of doing so we use gender labels and limit discussion to situations where men are perpetrators and women are victimssurvivors we entreat readers to recognise that these labels are not fixed or binary but form a useful heuristic for the purposes of this discussion finally we wish to acknowledge that the everyday practices discussed throughout this paper are not restricted to violent or abusive relationships they are utilised by people to minimise any sort of conflict and provide a basis for moving toward desired outcomes everyday peace theory social theory has sought to incorporate the everyday for generations with the concept explored by seminal thinkers including rousseau durkheim and marx and engels more recently the everyday has emerged as an explicit concern in itself rather than simply incorporated into the fabric of sociological and anthropological research the word everyday invokes ideas of normal ordinary activities undertaken on a daily basis the normal habitus for individuals and groups even if what passed as normal in a conflict situation would be abnormal elsewhere it excludes the extraordinary or exceptional everyday peace refers to the routinised practices used by individuals and collectives as they navigate their way through life in a deeply divided society it encompasses the actions people take to avoid or minimise conflict triggers and lay a foundation for more harmonious coexistence building on the work of multiple scholars we describe a series of common everyday peace practices perhaps the earliest scholar on everyday peace ring explored this idea with women living in an ethnically diverse apartment complex in karachi pakistan she argues everyday peace mostly occurs in domestic feminine spaces and observes three common themes underlying the womens behaviour acknowledging their huge emotional labour in maintaining peace themes she labels as tension anger and intimacy these are summarised in table 1 ring tension ongoing reciprocal kinlike exchange despite social tension to maintain connectiontrying to strengthen relationships and facilitate close reading of other people and the situation deliberately using the tension of asyetunreciprocated gifts or assistance as a means to build closer engagement anger in a context where explosive male anger was seen to risk escalating small misunderstandings into serious ethnic violence ring observed women labouring to protect themselves other women and their own men from anything that might trigger that explosive anger in her case women would quickly resolve differences with others in the apartment block or neighbourhood to avoid their husbands getting involved this sometimes included loud demonstrative acts to confront other perpetrators to convince their husbands the issue had already been dealt with so there was no need for them to involve themselves risking violence intimacy in rings context she identified a longing for intimacy as motivating women to sustain the tension of reciprocal neighbourly exchange across tense ethnic boundaries in the ipv context it may include behaviours such as choosing to maintain close daily engagement with a perpetrator despite the inherent tension out of a longing for intimacy mac ginty is perhaps the most prolific scholar on everyday peace he describes five social practices relating to intercommunal conflict avoidance ambiguity ritualised politeness telling and blame deferring these practices are briefly described in table 2 avoidance of highrisk conversation topics people places or situations and of behaviours that could be construed as offensive or inflammatory this may necessitate adopting a quiet and gentle disposition ambiguity using ambiguity to mask identity opinions and feelings including dissembling everyday speech with intercommunal conflict this can include discarding or hiding culturalethnic identifiers such as names specific clothing or areas of residence hiding things that could aggravate conflict practicing ambiguity includes choosing to ignore things that could cause conflict if raised ritualised politeness involving semiscripted overpoliteness that is often preconceived this practice seeks to promote peace by not causing offense tellingreading telling more aptly labelled reading a sensitised alertness constantly judging motives morals attitudes and feelings of others to read how and when to avoid or engage without provocation in an intercommunal conflict setting this includes constantly reading ethnicallyinformed identities of others for ipv this would focus on constant identification of the mood of the individual perpetrator blame deferring shifting the blame for the conflict or a negative incident to a third party the system or some people within their own group in ipv this may include offering excuses for the violence williams documents one more set of everyday peace behaviours exploring this from both the victim and perpetrator perspectives in her study of muslimhindu relations in a marketplace in varanasi india she suggests everyday peace is practiced mostly by those with less social power in this case muslims subjected to decades of hindu ethnoreligious violence for the sake of peace in everyday spaces relatively powerless people often opt to submit to injustice forgoing the right to seek justice for the threats and violence perpetrated against them at least for now to sustain nonviolent coexistence however on the flip side some of those with greater social power in this case hindusrecognise and abuse the fact the powerless have more to lose by renewed violence hence williams suggests that some choose to manipulate the everyday peace behaviour of the less powerful to maintain or further strengthen their position of power thus she suggests a potential dark side to everyday peace that is highly relevant to ipv importantly these practices are unlikely to operate in isolation two or more often overlap not all people in these situations practice these behaviours although avoidance is considered fairly ubiquitous and they do not do so all the time mac ginty frames these practices as acts of agency by people who seek nonviolent coexistence or more but feel largely powerless to affect the macro conflict in that sense everyday peace goes beyond conflictcalming or mere acceptance of negative peace the acts contain elements of resistance or subversion attempting to avoid certain things in order to protect safer spaces of engagement everyday peace to mac ginty thus involves action undertaken by largely powerless people to attempt to secure nonviolence hoping this could form a foundation for everyday diplomacy to later address justice issues and progress towards a positive transformed engaged peace with regards to ipv this suggests everyday peace could provide a framework to understand the behaviours and agency of women who choose to stay in abusive relationships and through understanding point to ways to support them beneath the macro policy approaches of government and formalised programs typically provided in the family violence space additionally practices of everyday peace could be presented as a softentry point for people unwilling to engage with traditional family violence supports as it works with people at the stage they are at rather than pushing them to make significant decisions which they may be unready or unable to enactparticularly noting the complexity and heightened risk level associated with terminating a violent relationship in doing this everyday peace accepts women as they are and respects the agency with which they live their lives we do not suggest women should tolerate violence rather everyday peace accepts their current choice and presents a framework to understand the agency of their current actions which could lead to new types of support being formulated to operate alongside existing family violence supports methodology this paper examines new narrative inquiry data from seven experienced female ipv practitioners to assess the significance and applicability of everyday peace to ipv it analyses written narratives provided by these practitioners working in the family violence space within four different nongovernment organisations across greater melbourne these practitioners have between seven and 30 years experience in the field and all have postgraduate qualifications in disciplines such as social work family violence and community development practitioners were purposively sampled based on expertise in the family violence space with considerations of sampling for diversity respondents are contacts of the authors or sourced via snowball sampling an invitation was extended to 17 practitioners with seven providing narratives two are culturally and linguistically diverse while one is otherwise diverse due to the small pool of participants we avoid providing more specific demographics narrative inquiry is a qualitative approach analysing using stories that describe human action it refers to any study that uses or analyses narrative materials respondents were sent four questions and asked to write a narrative stream of consciousness what everyday strategies have you observed or heard of that women use to 1 …avoid aggravating perpetrators and to maintain calm on a daytoday basis 2 …deescalate perpetrators when they are in a state of high arousal 3 …minimise immediate harm coming to themselves and their children when the perpetrator is acting abusively …try and move toward a positive sustainable relationship narratives were analysed thematically by the first author with the content within the text as the primary focus the narrative data was coded using the everyday peaceful practices outlined above as a theoretical framework so against rings tension anger and intimacy mac gintys avoidance ambiguity ritualised politeness tellingreading and blame deferring andor williams submission coded data were grouped according to similarities and subthemes identified evidence from the family violence literature on strategies was used to further test the applicability of the everyday peace practice themes three respondents volunteered to provide secondary analysis and critique on the first draft which was facilitated through a twohour focus group at this opportunity respondents suggested some examples should be relocated they also expanded on and provided additional examples application of everyday peace to intimate partner violence this section unpacks the relevance of everyday peace to family violence by presenting examples from the narratives of women in ipv situations using similar practices to minimise risk and conflict thus this section serves to demonstrate how everyday peace may apply to ipv and provide a foundation for further empirical research the subheadings relate to the practices documented by ring mac ginty and williams as above to assess the suitability of this theory for explaining ipv conflict minimisation and agency it is important to avoid essentialising all women experiencing ipv and recognise the complexity and variety of different womens responses the practices of everyday peace presented below are obviously not enacted by all women experiencing ipv some react in opposite ways seek external help attack back or act in open defiance of perpetrators efforts to control or terrorise individuals enact multiple strategies depending on the situation and feelings at the time however these examples were reported in the narratives and focus group tension in this paper rings identification of tension are conceived as themes of everyday peace that underlie the everyday peace practicesbehaviours of mac ginty and williams to follow ring discusses tension in the context of neighbourly exchange in which gifts help and reciprocal engagement between people across a difficult ethnic divide is deliberately maintained in the sort of manner usually reserved for kin and close friends however much of her conceptualisation of tension refers to the onedge tension women constantly feel as a result of hypervigilance in their intimate spousal relationship this has great relevance to ipv and womens everyday peace practices which respondent 3 suggests necessitate women navigating tense and often conflicting emotions between loving and hating their abusers craving and being repulsed by them feeling protected and vulnerable wanting to leave and wanting to stay respondent 3 adds that abusers can insert their own tension and anxiety to this mix through cyclical feelings of remorse guilt inadequacy and fear of abandonment additionally tension captures the pervasive and strengtheroding anxiety stress and mental burden of choosing to remain yet needing to tiptoe around an abusive partner and attempt to do everything right all the time to avoid reproach respondent 2 explains the juggling act women experiencing ipv have to undertake with their daily activities including purposively ensuring work shifts coincide with the perpetrators so he is not angered by her lack of presence when he is home and scheduling interactions with family violence workers and other social supports when he is not around respondent 6 refers to this as requiring women to sneak away to see family and friends while respondent 7 highlights that many women either have to sever relationships with family and friends or see them in secret respondent 6 also raises the tension felt by women who fear the actions of others and are compelled to ask family and friends to behave in a certain way around the perpetrator to keep the peace ring recounts an example of the tension women feel when trying to continue a friendship their partner dislikes or wishes her to sever she highlights that the tension of maintaining a friendship under conditions of secrecy time constraint and heightened risk…could only proceed if womens routine efforts to avoid and endure male anger were intensified this additional strain is unjust but women must choose between the heightened tension of losing a friend or enduring continued tension to keep them rings contribution though is noting the agency of women choosing to endure this tension as a deliberate strategy to work towards the sort of peace they hope to achieve anger ring describes male anger in her context as being widely seen to be illogical uncontrollable dangerous and unpredictable therefore women manage and accommodate it to avoid harm she uses many examples from her ethnographic research in pakistan including women downplaying abuse to avoid reigniting anger and women trying to be perfect to please their husbands by dressing modestly being religiously pious maintaining obedience and deference to their husbands never flirting staying at home not arguing not raising information that could anger him and boosting his sense of masculinity and dominance despite arguments about cultural divides and ethnicallydriven practices similar actions occur globally including within australia with women attempting to avoid abuse by being the perfect wife cooking cleaning and being demurely submissive while abusive relationships are an exertion of power through manipulation and control the potential outcome of not accommodating or managing these exertions is an outburst of anger this is how the manipulative and controlling behaviours utilised by perpetrators are so effective because they are backed by the threat of anger and violence rings everyday peace focuses on avoidance of anger even more than the subsequent violence it is anger that women adopt everyday peace practices to avoid they often accept other forms of abuse which have extremely detrimental impacts in an attempt to avoid anger as such the fear or threat of anger is a significantly pervasive and powerful coercive force which allows other aspects of abuse to foment and escalate respondent 6 mentions how women sometimes use anger themselves to shock or deflect the attention of perpetrators she gives the example of women putting themselves in the line of fire to protect children similarly respondent 7 discusses how women cover up childrens misdemeanours while respondent 3 notes that women may reprimand a child in front of their partner to show him that the matter has been dealt with to avoid further interaction between the perpetrator and child ring describes similar shielding behaviour with women stepping in to confront situations in such a way as to keep their spouse out of it intimacy in rings conceptualisation she discusses a deep longing for intimacy and friendship with other women as a motivator for women from conflictdivided ethnic groupings to enact practices of everyday peace similar to anger above this paper understands rings conceptualisation of intimacy as one of the motivations compelling women to engage in the intense and allconsuming peacepromoting labours necessary to manage and survive abusive relationships while there are many reasons for why women stay in abusive relationships respondent 1 suggests that in many cases at some early stage of the relationship if not now there was love and intimacy a desire to claim that intimacy can persist ring recounts her respondents beliefs that love is a dangerous force one fearful to women because it was seen to foreclose options to embroil one in an inevitable plot that erases agency and selfwill this is an interesting observation in terms of ipv suggesting intimate love results in a kind of possession and the loss of will extrapolating to ipv intimate love may be seen as the culprit that traps women in abusive relationships whereby love makes a person lose their rational senses as they become crazy or mad with love this relates to the ipv love bomb discussed by respondent 5 where the cycles of abuse phase through honeymoon periods of intimacy that hook women back into the relationship and keep them motivated to try harder to return to the honeymoon yet to ring there is a choice and agency in choosing to value intimacy thus regardless of interpretation an important starting point for ipv support raised by respondents surrounds understanding and respect for the choices women make without judgement where they are made out of reasoned agency there is a danger of support workers perpetuating gendered disrespect for women in ipv situations by not respecting womens choices or recognising this agency respondent 3 highlights intimacy as a motivating factor for practices of everyday peace that underlies several but not all of the reasons women remain in abusive relationships other examples including wanting to help their abuser codependency traumatic bonding emotional blackmail and eroded selfesteem further reasons are linked to anger additional reasons such as custody fears finances and logistics are important but are well covered by the extant family violence literature and out of scope for this paper the remaining subsections unpack practices of everyday peace as per mac ginty and williams girded by motivating factors of tension anger and intimacy avoidance of the five practices of everyday peace identified by mac ginty avoidance is probably the most commonly exercised in ipv situations in these situations avoidance practices fall into three key themes avoiding contentious conversations avoiding certain people and avoiding certain behaviours as family members seek to avoid upsetting or triggering anger through a range of strategies discussed below respondents note that conversations that may be perceived by perpetrators as nagging whinging blaming attacking or disparaging in any way may inflame conflict this can manifest in women ignoring financial and other concerns as well as what respondent 7 terms not calling out bad behaviour such as alcoholism drug use dangerous driving or draconian child discipline due to the inability to have open conversation to work through issues respondent 4 explains the need to keep the conversation neutral as such conversations that reignite a former argument violent incident or issue of contention are avoided or if unavoidable women may choose to quietly sit and wait for them to finish yelling at them or screaming or throwing things or whatever theyre doing respondent 2 comments that this includes avoiding discussing important things related to relationships and being quiet when verbal abuse escalates respondent 4 adds that while most women she works with say avoiding engaging in arguments with perpetrators can help deescalate the situation some women find that this can backfire and fire him up even more this highlights the complexity of ipv and reinforces that a onesizefitsall approach is obviously inappropriate yet avoiding triggers remains a common theme women may avoid being in the same area as the perpetrator when he seems aggravated which respondents note often include leaving the property or subtly moving children and pets into safer areas of the house additionally women may avoid raising past problems or talking about subjects that she knows could spark the perpetrators anger respondents identify that this can include pressure for women to disremember or minimise past trauma and wrongdoing caused by the perpetrator respondent 5 comments that this disposition of disremembering can become internalised and interpreted by human services providers as women downplaying the violence when in fact it may be a protective survival mechanism if a perpetrator is becoming escalated women may exercise meek acquiescence in an attempt to calm and deescalate them respondents note that this may include accepting being shouted over called names and physically attacked without responding respondent 3 mentions that to outside observers this may appear to be weakness but it is a welldocumented common sense method of avoiding conflict and hurt throughout the animal kingdom whereby submissive behaviour can calm a dominant attacker additionally she notes that these actions are not necessarily accompanied by terror and can be calculated and deliberate attempts to reduce harm women experiencing ipv may modify their friendship groups social interactions and family ties according to the wishes of the perpetrator with jealousy noted as a powerful trigger of anger respondents discuss that perhaps the perpetrator has a dislike for a certain friend possibly a friend who has seen through his charming façade perhaps the perpetrator is jealous of all the time his spouse is spending outside of the home in friendship groups that exclude him perhaps he is worried that she is going to meet someone who would be a better partner for her or concerned about friends who he thinks are a bad influence perhaps who have a moral compass that guides differently than his own which he may consider to be superior to avoid conflict women manage their social interactions with friends and family as necessary calling friends from their workplace using work emails avoiding events or leaving early and cutting or reducing contact with people the perpetrator considers undesirable in the era of covid19 and increased time at home four respondents highlight that this has manifested in the need for women to avoid talking to those contacts via video if they are likely to say something wrong that triggers the perpetrator respondents note the rise in ipv since the start of the pandemic respondent 3 mentions that the potential for contacts to say the wrong thing within earshot of the perpetrator is obviously a source of anxiety for women who may find total avoidance of that contact the easier route finally respondents explain that many women avoid behaving in ways they know will inflame the perpetrator this includes practices such as wearing clothes the perpetrator likes and avoiding pieces of clothing they do not like particularly if that item of clothing is a reminder of something that could trigger an outburst respondent 4 mentions that monitoring their behaviour includes avoiding eye contact and moving slowly and carefully so as not to get in his way while respondent 6 includes putting up with things he likes even if she does not and pretending to be interested in whatever theyre interested in respondents 6 and 7 include that women suppress their opinions and emotions women in family violence situations are forced to think more purposefully about their actions measuring their words before talking cleaning up or cooking dinner quickly if an ad hoc approach may anger being quiet and keeping the children quiet when he is watching a game or whatever specific triggers are applicable to that perpetrator mac ginty describes escapism into alternative activities as a form of avoidance respondent 4 offered examples in which women seek to distract perpetrators such as women carefully putting on the radio tv or a movie he likes or carefully using humour such as something funny a child did to divert a potentially dangerous situation sadly within the avoidance theme women in ipv situations sometime practice deflecting attention from themselves by minimising or sabotaging their achievements respondent 3 notes that this sabotaging is not selfsabotage as it is essentially caused by the perpetrator who directly or indirectly steers the woman toward turning down job offers or opportunities or pushes them to drop out of college respondent 7 explains this saying that men became threatened when their partners returned to school this was often because the women gained confidence and became more assertive expecting more for themselves with the limelight taken away from them perpetrators felt abandoned and fearful that their partners were drifting away so reinstated their control through presenting women with ultimatums one comment made by respondent 4 that does not cleanly fit into any of the everyday peace practices but most closely aligns with avoidance involves the subtle removal of objects that could be used to harm this may not only include potential weaponry but also links back to respondent comments regarding the subtle removal of children and pets from the perpetrators immediate vicinity and could include women keeping personally valuable items as well as potential weaponry away from perpetrators this interpretation includes the way that perpetrators often hurt people pets or things of value to women as a vehicle to cause her emotional harm in all of this the key contribution of the everyday peace framework is that it emphasises agency often within a very narrow range of perceived options but often active resistance or creative search for means to move towards better outcomes in the longerterm particularly in situations where the couple is no longer together there is evidence avoidance can help move the relationship toward positive peace respondent 4 notes that avoiding high conflict topics can provide space for a conflictfree future and offer potential for a healthy nonintimate relationship ambiguity practicing ambiguity in the ipv context relates to family members using vagueness to soften potential triggers and deescalate intensifying situations respondents identify how this necessitates women engaging in artful creativity to conceal dissemble and ignore subjects people and actions when identification may cause conflict and be deliberately ambiguous about feelings motives and actions concealing like many practices of everyday peace in ipv may relate to concealing the perpetrators actions and behaviours from others including social services as well as concealing and reshaping potential triggers from perpetrators respondents recall that women in ipv situations regularly conceal what is occurring from their external contacts for a variety of reasons including love for the perpetrator and a sense of loyalty whereby they do not want others to think badly of him and not wanting to draw attention to their family particularly to avoid the gaze of child protective services respondent 5 identifies that women may avoid drawing the attention of social services to prevent further conflict within the family as the infiltration of services shining a spotlight on the perpetrators behaviour is likely to raise his anger while respondent 2 mentions calling the police or lodging an intervention order as a help seeking strategy respondent 7 highlights that both of these are sometimes avoided by women in ipv situations who feel that calling out bad behaviour will inflame anger and violence in this manner concealment is a practice of everyday peace intending to minimise conflict concealment from perpetrators relates to women hiding or using ambiguity to blur something that could provoke a negative response an example provided by respondent 3 explains that women may relabel a female friend usually called sam to samantha in the perpetrators presence they may conceal ongoing friendships with undesirables by minimising contact with these people and never talking about them with the perpetrator in the hope they forget about their existence they may delete text or email messages or rename contacts on their mobile phones or computers by dissembling and disguising their true beliefs and feelings about a subject or action women seek to avoid inflaming conflict this can include actions such as downplaying a violent episode backpedalling on a conversation that is getting out of hand or masking the extent of their true opinion on a subject respondents note situations where women may ignore disregard or not see the perpetrators negative actions or behaviours this may be conscious and deliberate knowing that calling him out on them will incite conflict and would be unlikely to lead to a positive outcome or ameliorate the undesirable action or behaviour respondents list that this may include ignoring things the perpetrator says or does that she would like to stop such as swearing in front of children excessive child discipline drug and alcohol abuse property damage threats snide comments and a poor work ethic each of the practices of everyday peace can continue even if the couple are separated particularly if the couple have children and are expected to have some sort of ongoing relationship or contact as a result respondent 5 comments that in cases where a woman has an intervention order ruling that the perpetrator must maintain a certain distance from her and banning direct contact women may not report breeches and be ambiguous in their enforcement of the order to placate the perpetrator and avoid further conflict ritualised politeness ritualised politeness respondents note includes women being quiet and speaking softly and calmly respondent 6 lists several everyday practices to maintain perpetrators happiness these include paying attention to him and acknowledging his achievements andor bad day not giving the attention to the kids keeping the kids quiet not complaining asking permission to do something not taking phone calls or being on the phone in his presence cooking his favourite meal and making sure the house is clean and tidy respondent 7 classifies these actions as the women overfunctioning in the house and in the relationship which she explains as carrying the lions share of the household responsibilities and making things easy for him respondents note that women may adopt a false front of overpoliteness and tolerance at family gatherings business meetings or when friends are visiting to please the perpetrator respondent 7 provides the example of women tolerating visits from his mates including drinking sessions and late nights and bad behaviour however respondent 6 highlights that this is a fine line as she must entertain her partners friends but not be too friendly in case shes accused of having an affair even in cases where perpetrators are suffering psychosis and delusion women may politely acquiesce with insane narratives to avoid conflict respondent 5 comments that this can include agreeing with a perpetrators unhinged ideas such as a belief in his childrens immortality whereby offering agreement intends to prevent him from proving their immortality by attempting to kill them some perpetrators call their partners incessantly throughout the day despite it being annoying anxietyprovoking or inappropriate timing women often take the phone calls to avoid escalating the perpetrators paranoia and subsequent conflict respondents explain that women rarely know what mood they will be met with when they answer the phone calls and are braced to face the full range of emotions an exhausting and adrenalinewasting activity enacted to calm the perpetrator and maintain peace which is likely to have detrimental effects on womens mental health however switching off or not responding to messages or phone calls may have even worse repercussions with woodlock et al noting that this can exacerbate abuse respondent 2 mentions that having an alternate phone can help women who have left violent relationships remove themselves from this constant tension and take control of communication this social practice may also include women being docile and doing as the perpetrator asks without complaining questioning or hesitating respondents note this may become almost slavelike where the woman will fulfil the perpetrators demands almost regardless of negative effects on the family as the consequences of rebellion or assertiveness could result in worse outcomes as such respondents comment that women may give perpetrators sex buy them alcohol or give them money despite not wanting to or having insufficient funds for other needs respondent 4 highlights that this includes being obedient following instructions and getting him what he wants as well as anticipating needs and wants and attempting to deliver those to prevent any blowups respondent 4 also notes that avoiding these triggers in the short term is often to womens longer term detriment because it can ultimately lead to a bigger outburst when the family is financially crippled or if she leaves a massive financial burden for her maintaining the perpetrators happiness or approval can become allconsuming in line with rings observations discussed earlier about the emotional labour of managing these difficult situations in cases where the relationship has broken down but the couple need to maintain a connection for the sake of children respondent 4 highlights that these strategies can help move the relationship toward positive peace through maintaining conciliatory communication patterns following polite rules around transparency and processes and engaging in attempts to listen to one another and change behaviour tellingreading telling in mac gintys typology of everyday peace refers to a constant vigilance noting other peoples ethnicallyinformed identity in situations of intercommunal violence in ipv situations we note respondents observations of a constant noting or reading of the perpetrators fluctuating mood resulting in women adjusting their own behaviour based on this assessment this practice interlocks with the practices described above for example while certain conversations are avoided if women feel that they may provoke a response respondents note that there may be occasions when it is safe to raise that previously taboo subject depending on the perpetrators mood similarly respondent 6 suggests that women read the perpetrators mood when he comes home and act responsively for example having kids go into the bedrooms if the offender comes home in a bad mood respondents comment that women constantly monitor and assess this employing patience and emotional intelligence to determine safe and unsafe times to be in the perpetrators company or have a contentious discussion this telling or reading is both protective to quickly adapt to a perpetrators mood as well allowing women use this for their advantage many women experiencing ipv have great insight into the cycles of violence and are able to recognise and calculate probable outcomes an example provided by respondent 1 portrays a woman who utilises the honeymoon phase of a violent cycle when the perpetrator wants to give her gifts to collect items required for escape and reestablishment blame deferring with intercommunal violence a third party can often be blamed to allow actors from the other two groups to maintain a layer of everyday peace for example catholics and protestants in northern ireland could blame the british army in ipv where the conflict is usually localised between two individuals this needs to be played a little differently perpetrators and their partners may use blame deferring but for different purposes where perpetrators may deflect blame away from themselves to minimise their responsibility for their actions their partners are more likely to defer blame to placate the perpetrator and maintain peace womens manifestations of this practice of everyday peace fall into two key themes women may make excuses for the perpetrators behaviour and shift blame to others or themselves when talking to the perpetrator additionally they may make excuses to external people and services for consequences caused by the perpetrator in the first scenario women may seek to calm the perpetrator after violence or confrontation by shifting the blame away from him perhaps by denying the episode altogether or otherwise justifying the violence in an example provided by three respondents after violence women may offer that the perpetrator has been under a lot of stress or use his traumatic childhood or estranged relationship with his parents as an excuse for erratic and unacceptable behaviour respondent 7 clarifies that women sometimes say he doesnt mean it or he cant help it further women may blame themselves for the violence submitting that they should not have questioned his judgement cooked him that vegetable or deliberated before fulfilling the latest demand that required instantaneous obedience in the second scenario women offer excuses to deflect blame away from controlling and violent perpetrators in an example provided by respondent 5 a perpetrator controls his partners use of the car banning her from using it even when he does not need it she tells others that it is fine as she prefers to walk in another example from the same respondent a perpetrator prevents his children from sleeping at night due to shouting and slamming doors around the house when the children arrive at school the next morning late for class shambolic and yawning the partner blames rowdy neighbours when speaking to social services to request material aid respondents explain that women may manipulate the narrative to blame a third party in another example provided by respondent 5 if the perpetrator spent the last of the familys money on drugs or alcohol the partner could blame a direct debit or state that she had to spend the money on groceries leaving them short for the rental payment while this appears that women are protecting the perpetrators everyday peace notes the agency of these acts to protect themselves and their families knowing that any outside intervention comes with great risk of escalated harm if the perpetrator feels threatened or the loss of relationships and things they still hope holds value additionally respondent 3 notes that admitting that their partner has an addiction or is violent can be a source of shame for women and some rather maintain secrecy and shoulder the burden in private an intervention by child protection drug and alcohol or family violence services bring with them a similar stigma and the potential for increased domestic conflict providing women with an added incentive to deflect blame to a third party as such respondents identify that this everyday peace practice is enacted to reduce conflict with the perpetrator as well as to deflect unwanted attention and pressure from outside sources submission williams explores the topographies of power inequality that underlie a good deal of everyday peace practice including both submission surrender and renunciation by the less powerful party and the playing with power manipulation some employ to further strengthen their power in ipv this includes submission to injustice and renunciation of personal rights to maintain peace in the here and now and perhaps a goal or dream of addressing the underlying issue at some time in the future williams explains submission as actions that accept and conceal injustice and inequality through some level of surrender and acceptance of injustice at least for now this practice has disturbing elements that may undermine structural change and reinforce unequal power dynamics as well as being open to abuse however in the pursuit of a peaceful existence here and now surrender can be perceived as the best option available practices of submission in the respondents narratives are more worrying than some of the practices discussed above as they provide perpetrators with an additional layer of control and result in increased subjugation of the victim these include women informing perpetrators about their movements and interactions ensuring perpetrators know who she is meeting with where and when she will return gives perpetrators a feeling of control and security as such women may concede or be coerced into giving access to their calendars mobile phones social media accounts and emails which provides perpetrators with increased ability to perpetrate violence using technological means another common practice of submission involves giving in to perpetrator demands without arguing about them even when they are painful unwanted or detrimental to the family respondent 5 provides the example of women giving perpetrators access to credit or bank accounts despite it putting the family into debt or meaning insufficient funds remain to pay for essentials examples provided by other respondents include women giving sex making food or doing other things immediately when the perpetrator demands without resistance to maintain peace respondent 6 mentions that this can include agreeing with everything the perpetrator says to keep the peace and apologising even for something that is not their fault when out without the perpetrator respondents comment that practices of submission may include answering the perpetrators video calls allowing them to see who she is meeting with and assess the acceptability of the outing or sending the perpetrator photographs that attest to the fact that she is in fact out at a café with her mother these actions are usually subtle and others would be unlikely to notice anything out of the ordinary apart from possibly thinking it is nice her partner calls her so often and nice that she sends him photos of what she is doing woodlock et al highlight the crushing intrusiveness of these scenarios whereby perpetrators invade every aspect of a womans life giving him an omnipresence at least when the couple are in an intimate relationship the value of these actions as practices of everyday peace are likely to be far more detrimental than positive and actively reinforce and enable continuing violence this may change if a relationship breaks down with potential for submissive practices to enable space for positive peace and moving forward in a functional nonintimate relationship in analysing respondents narratives though we identified a further behaviour that we labelled as reassurance many perpetrators although notably not all suffer from significant mental health concerns and personality disorders or disabilities with deep insecurities low selfconfidence addiction and trauma this is not to excuse their behaviour but recognises that perpetrators frequently struggle through life focusing on this group of perpetrators respondent 3 raises that women often have a deep understanding of the perpetrators insecurities and seek to ameliorate nurture and comfort as best they can respondent 3 reinforces that this is not solely an altruistic behaviour as placating a perpetrators insecurities can be a practice of everyday peace intended to reassure to avoid paranoia and creeping conflict it can however also be conducted with the aim of addressing the underlying issues to deal with the ipv and arrive at a positive relationship in the longterm conclusions and implications for practice this paper explores the applicability of everyday peace frameworks to minimise and avoid conflict in ipv scenarios in the process it develops a theory to assess womens agentic actions this conceptual framework offers a different way to theorise womens survival strategies than those previously presented in the family violence literature where framed against seemingly strong strategies in the family violence literature such as resistance and help seeking most of these fit with socalled placating strategies which seem gentle unassuming and therefore weak throughout this paper we have reframed these peaceseeking strategies as agentic attempts to minimise harm and promote peace often conducted with deliberate and considered foresight into perpetrator behaviour and hoping to move towards outcomes the woman values reflective narratives of conflictminimising practices that practitioners have observed in practice were themed along with data on similar strategies found in the extant family violence literature around the everyday peace behaviour categories established by ring mac ginty and williams this analysis highlighted the significant overlap and relevance of everyday peace ideas between the state or community level to ipv at the household level this aligns with beckerblease and freyds research that found similarities between the trauma responses of war veterans and family violence survivors while the data from practitioners narratives largely fit within the everyday peace practices a theme around hiding raised by respondent 4 may suggest the need for a new category within the everyday peace typology removing dangerous items aligns with the avoidance category as it is an attempt to avoid harm however a separate theme on hiding could reinterpret some strategies currently grouped elsewhere such as where women hide friendships contact with services and other social connections items for escape and their opinions and feelings while clearly recognising that conflict minimising practices in ipv situations often negatively reinforce perpetrator control and entrench violence some of these practices have a positive application helping women avoid harm and potentially moving towards longterm outcomes they value they are often deliberate conscious acts by women demonstrating considerable agency in difficult circumstances they also constitute a foundation upon which further agency may be developed empirical findings confirm that these strategies can increase risk of harm in some instances particularly as abusive perpetrators tend to naturally escalate over timemaking placating strategies less effective further as respondent 6 comments most of the women i work with have already left the family home they voiced that these strategies have sometimes worked they have sometimes helped to appease the offender however the offenders propensity for violence always won out when he was in a really bad mood or very angry at that point in time no strategies would keep the women and children safe and often they would be assaulted this highlights the complexity of family violence and the importance of avoiding suggestions that everyday peace practices in ipv situations are automatically helpful or effective nonetheless respondents note that the strategies outlined throughout this paper have protected women and children from immediate harm and minimised conflict to some extent as well as developing womens agency ability to manage and insight into violent cycles which can strengthen their psychosocial outcomes during and after the abusive relationship thus while recognising the limitations of these strategies having a framework to organise and understand these practices could help family violence workers acknowledge the strength and agency exhibited by women experiencing ipv it could provide workers with strategies to support harm minimisation that build on womens own ways of handling the violence in their lives an obvious limitation of this paper is that it is based on practitioner experience it would be beneficial to employ this framework through empirical research with women who experience ipv and understand the actions they take to minimise conflict in their families from firsthand sources this would add to the growing literature seeking to hear the voice of women and understand their experiences of violence from their emic perspectives although recognition of womens agency and ingenuity through everyday peace practices is useful and important it is essential to acknowledge that these practices in many ways pander to and reinforce violent behaviours rather than simply celebrating womens ability to survive these oppressive situations the authors note the fundamental need for concurrent work to raise consciousness around gender equity and address oppressive social structures that continue to subjugate and constrain women additionally it is important to note that the everyday peace practices women enact in the private sphere are no replacement for formal family violence supports such as those provided by community services organisations and the police

this paper assesses the transferability of the recent concept of everyday peace developed in the conflict and peace studies literature as a mechanism for understanding agency to minimise harm and seek nonviolent coexistence to practices utilised by women experiencing intimate partner violence ipv this paper thus scopes the relevance of everyday peace to ipv by mapping womens behaviours to manage and survive abusive relationships as identified through the family violence literature and practitioners narratives against various typologies of everyday peace the empirical component of this study involves analysis of new narrative inquiry data from experienced family violence practitioners against the literature to consider whether women experiencing ipv adopt practices similar to those documented in the everyday peace literature the practitioners were asked to recount practicebased information about everyday strategies that women use to avoid triggering or to deescalate a perpetrator thereby minimising immediate harm coming to themselves or others and any strategies used to build more peaceful coexistence theming these behaviours against typologies of everyday peace in the conflict and peace studies literature demonstrated significant relevance of this theory to ipv as such we suggest that everyday peace is a useful conceptual framework to apply to family violence our analysis finds the everyday peace framework is particularly helpful in exploring agency in these contexts reframing womens mundane and everyday strategies as agentic as such this analysis finds everyday peace offers a means for understanding womens agency actions which could be used to develop more effective service responses to support womens choice and agency in ipv situations

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introduction on 11 march 2020 when the world health organization declared covid19 a global pandemic the socalled world war iii on coronavirus prompted countries worldwide to announce their respective national emergencies to fight against the global enemy by mandating healthensuring protocols international travel closures business and institutional lockdowns or limited operation and most importantly researching and developing effective covid19 vaccines for crisis control facing covids hard landing as early as early december 2020 and january 2021 the covid19 vaccine race kicked off the first vaccination in the uk and israel followed by the us and many others in the common goal of demolishing the enemy 1 following individual or joint efforts and extended attempts as many as 21 covid19 vaccines led by moderna and janssenjohnson johnson of the us astrazeneca of the uk pfizerbiontech of germany and sinovac and cansino biologics inc of china have been launched in countries globally covering 603 of the world population with at least one dose injection since january 2022 momentously this adds up to a total of 98 billion doses already administered while currently 288 million daily shots are reported to be given to increase the vaccine coverage 12 since the global rollout countries receiving high vaccination coverage vary greatly in their levels of economic development and social and political arrangements including the united arab emirates at 92 full vaccination and 7 part vaccination portugal at 90 and 4 respectively cuba at 93 chile at 91 singapore 89 china at 88 canada at 84 followed by italy japan france in between before vietnam at 79 brazil at 78 the uk at 76 and the us at 75 alongside germany heading the rest of the world nonetheless extremely low vaccination rates of 94 have been observed across lowerincome and underdeveloped nations where ethiopia and nigeria were victims of the frailty in their economies and politics as recently emphasized by the who in promoting the goal of vaccine equity no one is safe from covid19 until everyone is safe since the disease is believed to be under control or possibly ended only when vaccination is nondiscriminatory across all countries from the most powerful to the most vulnerable given whos target of 70 global vaccination presumed necessary for herd immunity and facing the pressure of a virus moving faster than the global vaccine distribution it is a global priority task to reallocate fairly distribute and administer the vaccines from countries with a surplus to those experiencing a shortage to prevent the pandemic from worsening 3 within the united states president bidens administration has pledged a national effort in the struggle against covid19 since early 2021 the covid19 vaccination race has encompassed various groups across all ethnicities genders and almost all ages as of january 2022 including the initial and booster shots high vaccination has been reached in the us northeast pennsylvania virginia and new england the west coast oregon california and a couple of midand southwest states namely new mexico and colorado their lowerrate counterparts are typically spread across the centraleastern coastal regions georgia the southern midwest mississippi oklahoma and midand northwest idaho north dakota leaving the medium achievers such as arizona texas and nevada 4 given such asymmetric crossstate coverage this paper investigates whether and how the covid19 vaccination is affected by macroeconomic and sociopolitical factors such as personal income employment status education race and ethnicity age occupation rural vs urban dwelling and political preference across 443 counties in the states of arizona colorado new mexico oklahoma and texas since the outbreak of covid19 studies across almost all fields and dealing with almost all aspects of the public health crisis have appeared in record numbers in the literature from the debates over the origin of the virus to the effects of covid19 vaccination more recently the intellectual development and exchange have been dynamic innovative and prolific given this analysis centering on the context of covid19 vaccination relevant literature is summarized in the subsequent subsections mentality on covid19 and attitude toward vaccine acceptance internationally the public acceptability and attitude toward the covid19 vaccine have been reported as being low elelimat et al 5 attested to the case of jordan where low acceptance is rooted in concerns over vaccine safety following incomplete nontransparent or misleading vaccine information likewise machingaidze and wiysonge 9 claimed vaccine hesitancy in the study of lowand middleincome countries across africa south asia and latin america although vaccine acceptability may seem to vary in those countries higher acceptance is believed only to occur when vaccine safety is high with low or no vaccination cost and the vaccinerelated information is trustworthy as emphasized in the oxford coronavirus explanations attitudes and narratives survey personal over the collective benefit of vaccination should be a key driving factor in increasing group immunity 10 in chile covid19 vaccine refusal or indecision has also been noted reflecting concerns about the vaccines side effects and effectiveness the perceived benefits for the injected and his community the availability of disease and vaccine information and the pandemic trend 11 12 13 similarly majeed et al 14 alerted that the lack of data and analysis on longterm vaccine safety and efficacy tends to contribute to british vaccine hesitancy as claimed by cascini et al 15 global herd immunity against covid19 could be impeded by vaccine hesitancy across countries including barriers of negative vaccine perception especially among those with lower income and educational level not medically insured and ruraldwelling as well as selfidentified ethnic minorities kaplan and milstein 16 suggested that in the us vaccine acceptance improved when the efficacy increased beyond 70 contrary to a low acceptance when the probability of severe adverse reactions ascended covid19 vaccine safety and efficacy facing acute and highly transmissible covid19 vaccine safety and efficacy are crucial factors a countrys citizens assess before their vaccination decisions polack et al 17 reported that a twodose covid19 vaccine by bnt162b2 mrna reached 95 protection in persons 16 years and older while severe side effects were low and comparable to other vaccines and placebo groups in the same perspective some studies have produced equally comprehensive reports including different vaccines under respective production platforms inactivated virus vaccine subunit vaccine dna vaccines and rna vaccines with specific advantages and limitations 1920 collectively it offers vaccine developers a key reference and general vaccine information on shortterm vaccine efficacy and safety to the public alternatively rodrigues and plotkin 21 identified health economic and social benefits upon the receipt of covid19 vaccination suggesting broader immunization to alleviate the pandemic socioeconomic and sociopolitical impact on covid19 vaccination ironically the coronavirus brings about not just a purely medical catastrophe its complexity is rather allencompassing involving socioeconomic conditions and politics which impact the outcome of vaccination boserup et al 22 for instance uncovered the disproportionate impact of covid19 with higher virus infections and deaths on racial and ethnic minorities in the us alerting the need for vaccination across these minorities to stem the spread garcía and cerda also suggested the socioeconomic characteristics of the community be considered so as to implement an adequate and proper public health policy for covid19 control 12 recent studies have disclosed that the political divide along with income and racial disparities affected covid19 casualty and vaccination rates as republican voters were less willing to be vaccinated leading to significantly higher disease cases and deaths 23 24 25 similar evidence of covid19 being a politicized issue is also revealed in social and public media such as twitter 26 while blacks tended to express reservations about vaccine safety and efficacy during the 2009 h1n1 influenza pandemic 27 structural racism and ethnic inequities against minorities such as hispanics and black americans hampered the overall covid19 vaccination rate pointing to possible social structural change as a means to improve immunization across all races 2829 this study aims to outline the socioeconomic and sociopolitical behavior of regional citizens reacting to the covid19 vaccination in hopes of offering local state and national policymakers a better understanding to properly prepare and strategize the next steps or plans to end or coexist with the disease the paper is structured as follows the section 1 starts with an introduction the section 2 summarizes the materials and methods the section 3 of results analyzes the empirical findings the section 4 offers discussion and policy implications followed by the section 5 conclusions materials and methods data sources and variables countylevel covid19 vaccination rates counting adults aged ≥18 years who were fully vaccinated as of 1st may 2021 were analyzed in this study the analyses are based mainly on five sources of data bureau of labor statistics bureau of economic analysis 2010 us census politico and centers for disease control and prevention covering an aggregated dataset of a total of 443 counties across all five states in the midand southwest from the outbreak of covid19 until mid2021 various independent variables covering socioeconomic and political aspects at the county level with respective data sources were included as described below and shown in table 1 age1864 percent of county resident population aged between 18 and 64 age65over percent of county resident population aged 65 years and over age14over percent of county resident population aged 14 years and over age18over percent of county resident population aged 18 • income the covid19 pandemic has created much economic hardship for most people as different income levels may potentially increase the acceptance or refusal of the vaccine this study hence tries to disclose the effect of per capita income on vaccination following the data from the bureau of economic analysis with the fundamental prediction resting on the higher lags in vaccination rates among counties with lower income • race and ethnicity race and ethnicity are exogenous variables and important indicators in this analysis which aims to offer policy implications possibly reducing racial and ethnic disparities to improve overall covid19 vaccine coverage across five states cdc identified racial and ethnic discrimination amid other factors creating challenges to covid19 vaccination access and acceptance among minority groups 33 thus it is assumed that lower vaccination rates prevail in counties dominated by minorities of blacks asians native americans and hispanics diverging from those predominantly inhabited by whites and nonhispanics statistical method a preliminary summary of countylevel factors and vaccination rates was analyzed in table 2 arcgis was used to map the spatial distribution of the vaccination rates and show how socioeconomic and political variables impacted covid19 vaccination across counties and states linear regression analysis was used to examine associations of socioeconomic factors with countylevel vaccination rates based on the multicollinearity detection using variance inflation factors and correlation plot seven variables were selected for inclusion in the default model as follows m1 vaccinationrate β 0 β 1 state β 2 unemployment β 3 democrat β 4 farmworker β 5 ruralpct β 6 hsgraduate β 7 income where β 0 refers to the intercept of the vaccination rate and β i denotes the coefficients associated with the covariates we then added each age variable to model 1 to examine the adjusted effects by population percent of various age groups model 2 has the following formula m2 vaccinationrate β 0 β 1 state β 2 unemployment β 3 democrat β 4 farmworker β 5 ruralpct β 6 hsgraduate β 7 income β 8 age where β 8 refers to the coefficient of each agespecific variable table 3 tables s1 ands2 show the estimated coefficients obtained for the model with age65over age1864 and agemedian respectively as the next stage each racespecific variable was added to model 2 to explore the raceethnicityspecific relationship with the vaccination rate as given in model 3 m3 vaccinationrate β 0 β 1 state β 2 unemployment β 3 democrat β 4 farmworker β 5 ruralpct β 6 hsgraduate β 7 income β 8 ageβ 9 raceethnicity where β 9 refers to the coefficient associated with each raceethnicity variable the separate model for each racial and ethnic variable was identified in table 3 tables s1 ands2 all statistical analyses were conducted using the software r the level of significance was set at a pvalue of 005 challenges to covid19 vaccination access and acceptance among minority groups 33 thus it is assumed that lower vaccination rates prevail in counties dominated by minorities of blacks asians native americans and hispanics diverging from those predominantly inhabited by whites and nonhispanics statistical method a preliminary summary of countylevel factors and vaccination rates was analyzed in table 2 arcgis was used to map the spatial distribution of the vaccination rates and show how socioeconomic and political variables impacted covid19 vaccination across counties and states results figure 1 illustrates relationships between socioeconomic and political affiliations and covid19 vaccination rates across the midsouthwest region overall vaccination rates as of 1st may 2021 ranked from highest to lowest by state were arizona new mexico texas and oklahoma and colorado in sum the likelihood results figure 1 illustrates relationships between socioeconomic and political affiliations and covid19 vaccination rates across the midsouthwest region overall vaccination rates as of 1st may 2021 ranked from highest to lowest by state were arizona new mexico texas and oklahoma and colorado in sum the likelihood of vaccine acceptance was found to be positively associated with countylevel personal income and the level of unemployment it suggests that county citizens with higher personal income would tend to seek vaccine protection under the rationale that vaccination is widely believed to help one keep hisher job which then secures hisher income likewise the unemployed across counties and states would tend to be vaccinated in order to use the proof of vaccination to find their next employment alternatively the map of political preferences shows a pattern of higher vaccination rates in counties with a higher percentage of democrat votes than of republicans which is especially true for the democrat counties including apache and santa cruz in arizona and mckinley cibola and los alamos in new mexico as a mirror reflection the highest correlation of vaccination rate and democratic affiliation was observed at r 039 as shown in figure 3 this finding aligned with the claim of bardosh et al 34 which emphasized that political and social polarization may end up with reverse causation leading to adverse vaccination effects figure 2 indicates that county vaccination rates correlate with percentages of the county population by race and ethnicity in general there appears to be a negative relationship between vaccination rate and the black population while there is a positive correlation with hispanic groups this result resonates with the study of kricorian and turner 35 in a recent vaccination survey claiming that black americans were less likely to want the covid19 vaccine at all compared with whites and hispanics and mistrust of the vaccine among black respondents was significantly higher than other racialethnic groups meanwhile the latest data on covid19 vaccination by raceethnicity corresponding to cdc reports indicates that by 31 january 2022 74 of americans across all races and ethnicities had received at least one dose of a covid19 vaccine 36 among them whites who represent 61 of the total population make up 56 of people with at least one dose hispanic citizens who represent 17 of the total population reach 20 of the onedose vaccinated while blacks who represent 12 of the total population make up just to 10 of individuals who received at least onedose followed by other minorities such as asians at 6 of the total population and 7 of the singleshot group in the correlation plot of figure 3 the vaccination rate was lower among counties with higher proportions of whites and blacks while opposite relationships were observed for asians native americans and hispanics this indicates that across the five states hispanic residents may be more inclined than blacks and other minorities to accept virus protection and choose vaccination weak correlations were found between raceethnicity and socioeconomic factors except for the negative association between the percentage of high school graduates and hispanics table 2 includes a preliminary summary containing the descriptive statistics for the socioeconomic and political variables and vaccination rates across all 443 counties and the respective number of counties within each state as of may 2021 the mean of countylevel vaccination rate in the midand southwest regions was 2459 with the lowest in colorado and the highest in arizona in particular counties with higher average vaccination rate in arizona had a higher percentage of democrat votes and a population aged ≥65 years while these counties were endowed with the lowest population of farm workers the lowest percentage of rural population and the lowest income per capita on the contrary colorados counties on average attaining the lowest statewide covid19 vaccination rates showed the highest income per capita the highest percentage of whites the most highschool graduates but the lowest unemployment rate with regard to such socioeconomic vaccination differences between arizona and colorado it is somewhat evident that with the comparable number of black residents in both states the vaccine coverage among whites in colorado seemed deficient and lingering as compared with arizona moreover colorado had significantly more farm workers and a greater proportion of rural land than arizona this could logically be linked to its lower statewide vaccination rate since its farm labor may disperse across more extensive and remote rural areas facing less worrisome virus transmission lastly in the 2020 presidential election states with more counties that voted for the democrats for example arizona and new mexico tended to have higher vaccination rates states with more counties classified as urban areas such as arizona and new mexico were more likely to have higher vaccination rates hypothetically the higher urban vaccination rate reflects the population cluster effect as city people would receive vaccines to avoid virus infection due to their relatively close contact with others key regression results from different model specifications between the countylevel characteristics and vaccination rates are described in table 3 in model it is observed that the countys state democratic affiliation and income per capita were significant factors influencing the percentage of those vaccinated in the county the state variable was shown to be an important categorical factor in predicting vaccination rates for respective counties because each county has the characteristic of being dependent on the state as its administrative subdivision increases in vaccination rates were associated with a higher percentage of the democratic vote and per capita income when each age variable was added to the model the increase in the population aged 65 years or older had the most substantial and positive effect on the change in the vaccination rate among other age variables followed by a significantly negative impact on the change in the vaccination rate in the age group of 1864 years and a significantly positive effect on the change in the vaccination rate with respect to the median age group as the corresponding estimates and 95 confidence intervals are shown in figure 4a that is model containing individuals aged ≥65 years performed the best by explaining 404 of the total variation in vaccination rates in general the vaccination rate would increase by 0245 per one percent increase in the elderly population in a county nonetheless as the model included a population aged between 1864 years old it showed that the vaccination rate would decrease by 0265 per one percent increase in this age group finally when the model was adjusted for the median age it was found that the vaccination rate would increase by 0222 for a oneyear increase in the median age of the county population given the above agevaccination factor the model corrected for the age ≥ 65 which produced the most significant effect on the covid19 vaccination rate was selected each race variable was added to m2 to explore the effect of specific countybased racialethnic densities on vaccination as tabulated in models m31m35 of table 3 the calculated vif indicated no significant multicollinearities between the raceethnic variable and socioeconomic factors particularly for the correlation between hispanic and high school graduate percentages in m35 explicitly it showed that the vaccination rates increased with increasing percentages of native americans and hispanics and decreasing rates of the black population whereas the white and asian population effects were not significant in predicting a countys vaccination rate in terms of the role of socioeconomic factors this suggests principally that native americans and hispanics would be more likely to seek and accept the covid19 vaccination than their black counterparts while such likelihood was not evident among whites and other minorities in figure 4b the 95 confidence interval was mapped to illustrate such raceethnicityvaccination relationship displaying statistically significant and positive effects on the change in the vaccination rate from indians and the hispanic group contrasting with the significant but opposite effect contributed by the black citizens equally tables s1 ands2 summarizing the analytical results over different age variables revealed the consistent connection between vaccination rates and the raceethnicity variables finally a couple of additional points are worth noting in table 3 model m32 including black as a race variable explained 488 of the variation in the vaccination rate the results imply racial disparities particularly among blacks regarding covid19 vaccination coverage as claimed by kricorian and turner 35 for all the models adjusted by age and race variables we observed consistent results for the countys state democratic affiliation and income per capita as significant factors affecting vaccination rates however the rural residence of county citizens was found to be negatively correlated with the vaccination rate in the native american model in table 3 showing a decreasing rate of vaccination among those who dwell in the county with more and more remote rural areas discussion and policy implications discussion and policy implications since the outbreak of covid19 as all people around the globe are under siege policymakers from almost all levels and fields have tried to work and race against time to cope with and defeat such an unprecedented deadly enemy after two long years of battle many countries still see covid19 as a national threat needing continuous efforts to fight it while believing that a change in life seems inevitable in the long run after the individual and collective research and development effort to develop the covid19 vaccines the launch of vaccination was like the dawn of a new day giving hope to the global community although the global vaccine coverage is far from complete in the us the crossstate vaccination race started in early 2021 while the entire nation continues to work industriously to increase the national vaccination coverage factors affecting covid19 vaccination across the states are proved to be multifaceted hence the policies proposed for vaccination promotion should be pragmatic and strategic targeting both factorspecific schemes and taking a generalized approach no one is safe from covid19 until everyone is safe 3 indeed getting covid19 under control is revealed to be when a population is by and large vaccinated from every individual in a country to the entire population worldwide herd immunity and vaccine equity across countries are crucial while practical actions to increase vaccination rates are the real need within the us vaccine equity may only be a reality when citizens of all races and ethnicities are reached for vaccination policymakers are recommended to understand fundamental ethnic culture and differences while practicing no racial discrimination to promote civilian trust and expand vaccination political preference matters as indicated in the empirical findings countybased politics faces a political divide showing democratic voters tending to receive covid19 vaccination more than their opponents is it not time to think beyond politics the republican political leaders along with their democratic and other political rivals need to persuade their respective followers that living or being alive is and should be above all things policymakers are therefore advised to work with politicians of all parties to communicate with their supporters about lifesustaining protection through vaccination as the number one priority personal income leads to vaccination variation in this study percapita income appears to affect covid19 vaccination across counties when citizens facing economic and financial struggles tend to delay or decline immunization even if the cost of covid19 vaccination across the us is generally covered by citizens medical insurance or sponsored by the state or federal governments lowincome or underprivileged individuals and households should not feel stressed when getting vaccinated other socioeconomic factors such as occupation relevant to personal income also need further discussion studies have found that covid19 has exacerbated income and socioeconomic inequalities which implies that a proper vaccination policy must be designed to support various occupations such as environmental services workers who appear to be covid19vulnerable 37 policymakers are suggested to provide equal access including assistance with vaccination registration and transportation logistics especially when such resources are unavailable or less accessible to those citizens conclusions in conclusion it is found that us countylevel vaccination rates were significantly associated with the percentage of democrat votes per capita income and the state to which the county belongs pertaining to age differences an increased county vaccination rate was observed as the percentage of the elderly population increased whereas it decreased as the share of the county working class population aged 18 to 64 increased countylevel differences in racial and ethnic covid19 vaccination acceptance prevailed showing that vaccine acceptance decreased with an increasing rate of the black population counter to an increasing vaccination rate in counties with more native americans and hispanics this study serves to alert policymakers to the potential vaccination impediments while it data availability statement the dataset supporting the conclusions of this article is available in the mendeley data repository accessed on 15 june 2021 advises the public that for the goal of pandemic alleviation and crisis recovery increasing vaccination would presumably be fundamental supplementary materials the following supporting information can be downloaded at mdpicomarticle103390epidemiologia3040038s1 table s1 associations between vaccination rate and the counties characteristics in the regression analyses including the age group of 1864 years table s2 associations between vaccination rate and the counties characteristics in the regression analyses including the median age group

since the outbreak of covid19 vaccination against the virus has been implemented and has progressed among various groups across all ethnicities genders and almost all ages in the united states this study examines the impacts of socioeconomic status and political preference on covid19 vaccination in over 443 counties in the southwestern united states regression analysis was used to examine the association between a countys vaccination rate and ones personal income employment status education race and ethnicity age occupation residential area and political preference the results were as follows first counties with higher average personal income tend to have a higher vaccination rate p 0001 second countylevel vaccination is significantly associated with the percentage of democrat votes β 0242 p 0001 third race and ethnicity are vaccineinfluencing factors counties with more black residents have lower vaccine acceptance β 0419 p 0001 while those where more hispanics or native americans reside are more likely to accept vaccines for health protection β 0202 p 0001 β 0057 p 0008 respectively lastly pertaining to the age difference seniors aged 65 and older show substantial support for vaccination followed by the median age group all p 0001

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introduction across the globe there are roughly 850 million people who remain chronically hungry 780 million people without access to clean drinking water and 25 billion people without access to sanitation facilities for decades international development agencies have loaned invested and donated billions of dollars worldwide to combat poverty and work to provide everyone with these basic human rights such as food water shelter and healthcare the official development assistance of 127 billion dollars in 2012 includes disbursements from the organization for economic cooperation and developments development assistance committee in addition to government distributions there are billions of dollars more in expenditures from both private philanthropic and nongovernmental organizations each year the bill and melinda gates foundation alone spent 26 million dollars on global grants and programs during the 2012 fiscal year these massive resources are allocated through international aid loans investments or a combination of these and other efforts in the current economic climate both public and private organizations are pushing for strong accountability of expenditures and proper utilization of funding often the associated projects fail to meet intended objectives for any number of reasons including but not limited to a lack of local perspective from project implementers trying to accomplish too much in a short timeframe or not having social capital or support for continued project success after implementation for example a comprehensive external review of 133 completed world bank projects showed that 50 of projects failed to meet the original objectives of the project as a sector example the percentage of water and wastewater treatment projects that fail to be sustained for long term use ranges from 10 to 75 with commonly found estimates that state half of all water projects fail within 5 years due to the ineffective development interventions there is an increasing need to select and prioritize a project for funding that has the highest potential for longterm success these multifaceted factors lead to choosing projects to allocate funds using a variety of complex multicriteria decisionmaking techniques there are many multicriteria decision techniques for modeling decisions including optimizing and prioritizing project selection in various settings some popular techniques include information system approaches such as the topsis method the promethee method the goal programming model nonlinear integer programming and a number of others as described in several review papers one decisionmaking technique that has previously been utilized for project selection of research and development programs is the analytic hierarchy processanalytic network process while other techniques have notable benefits the ahp has been highly regarded because it can relate any element of a complex problem to a quantitative measurement even if the problem has difficulty to quantify components classical project selection models focus more on the individual attributes of the candidate projects and therefore the decisionmaking criteria do not account for the interdependencies among alternative projects some project selection studies realized that interdependencies exist among alternative projects and proposed nonlinear programming formulations to address the resource benefit and technical interdependencies among candidate projects however one type of project interdependencies ie the interorganizational communications and social relationships has never been considered in existing multicriteria project selection models it should be noted that some studies have considered interorganization factors in multicriteria decision making models although these models do not focus on project selection and interorganizational social relationships trust and communication between project coordinator and task manager are critical factors in successful development projects another study of successful development project criteria in southeast asia suggests that using participatory planning and stakeholder participation will lead to more successful projects the relationships between an organization and the broader network of entities working in the international development community have strong implications for the overall functioning of that organization global civil society which refers to the large array of nongovernmental organizations worldwide has often been referred to as a highly networked and relational group ozturkoglu and turker sought to analyze stakeholder relations given relative power and interests and found significant differences between public organizations banks and financial institutions universities and nongovernmental organizations in turkey the social relationships between development agencies nongovernmental organizations private companies and other groups working on development projects play an important role in the overall success of projects and the working community as a whole the interorganizational communications and the social relationships between organizations can be considered as a new set of evaluation criteria in the project selection model these communications and the social relationships criteria can be measured by applying metrics developed in social network analysis sna investigates the connections and relationships among social entities and draws patterns and implications from these relationships like all network analysis it is based on the assumption that there is importance in the relationship among the interacting units investigating the network structure and properties is the most common method of analysis used in organizational network research the metrics based on the network structural data can investigate the causes of structures or the consequences network analysis is wellsuited for investigating the relationships of organization communities such as research for development groups that rely on research outputs being utilized by other groups as a sign of effective programs interorganizational communications and the social relationships could be integrated into a variety of multicriteria project selection methods however the anp model was chosen because it allows for practical integration of social network data within its easytocomprehend formulation this indicates anp is an excellent choice for organizations in the development community interested in leveraging interdependencies with project selection procedures due to these factors integrating social network analysis with the anp could yield more successful outcomes and development interventions throughout the world this paper is motivated by realworld practical needs arising from the perspective of a donor organization in the water and food security research for development network in the mekong river basin in the broader research for development community context these needs can be characterized as follows first there is the need to select and fund project proposals that will succeed in meeting research or development goals second a donor organization also seeks to increase its social capital by strengthening its standing in the network of organizations within the given field by connecting with the key players in the social network while bridging these two important gaps in the current literature this paper illustrates the application of a multicriteria anp model for international development project selection that integrates social network relationships into project selection which can be applied to numerous disciplines in addition to project selection outcomes leveraging traditional applications of anp in conjunction with traditional social network analyses can also serve to further and strengthen social network analyses empirical data from a social network of research for development organizations in the mekong river basin is used to analyze the proposed model this model can be a systematic tool resource for development donors and grant recipients in the mekong basin and the larger research for development community worldwide building social network criteria into an ahpanp model allows for the development of this model that can be applied in many project selection problems in multiple disciplines however to the best of our knowledge none of the existing decisionmaking model approaches factor the interorganization relationships in the project selection process analytical formulation assume there are m projects that are under consideration by a donor the donor has a set of criteria denoted by fe j jj ¼ 1 ng for project evaluation let each project be associated with a final numerical score s i i ¼ 1 m the project selection process is to determine the scores s i based on the given criteria fe j g through a multicriteria decisionmaking model such that the set of projects can be prioritized according to their scores s i and the optimal alternative can be identified in this study anp is employed as the multicriteria decisionmaking model to determine the scores s i of candidate projects in the rest of this section a brief review of the anp will be presented first followed by the social network analysis and the proposed integrated model analytic network process anp is a comprehensive model that is appropriate for making multiobjective multicriterion and multiactor decision with and without certainty for any number of alternatives as the anp is a generalization of the ahp we first review ahp in this section ahp was developed in order to quantify the importance of a set of criteria in a multicriteria decisionmaking problem since ahp is based on easy to understand value rankings it has been used and applied by companies and organizations in the real world whereas more mathematically complex models may not be easily transferred from advancing research theory into real world practice additionally ahp models have been used effectively to optimize project selection in the research and development settings a classical ahp can be constructed as follows the goal criteria and alternatives form at least three levels of a linear hierarchy tree after determining the overall goal and the criteria and alternatives for a particular decision the pairwise comparison can be obtained this pairwise comparison can be based on value choices from individuals involved in the decisionmaking and are often based on a 19 scale of importance let a ij denote the comparison of the strength of criterion i to criterion j based on a priority vector w ¼ ðw 1 w n þ for the overall goal criteria and alternatives determined by the decisionmaker the pairwise comparison of criterion i to criterion j is computed by a ij ¼ w i w j similarly a ji ¼ w j w i and thus a ji ¼ 1a ij then for the set of decision criteria e ¼ fe j jj ¼ 1 2 ng the pairwise comparison of n criteria can be summarized in the matrix a ¼ a 11 á á á a 1j á á á a 1n a i1 á á á a ij á á á a in a n1 á á á a nj á á á a ji ¼ 1a ij a ij 0ð1þ where every element a ij ði j ¼ 1 2 nþ is the quotient of weights of the criteria the priority vector or relative weights of the set of criteria are determined by the right eigenvector w of matrix a which corresponds to the largest eigenvalue k max ie aw ¼ k max w this is necessary because the matrix is formed based on human value judgments which are intrinsically inconsistent and this method can provide validity of the priorities of a decision a pairwise comparison and subsequent eigenvalue calculation is completed by the decisionmaker for each criteria and set of subcriteria the final score of s i i ¼ 1 m for each alternative is obtained by summing each alternatives relative weight with respect to each criteria multiplied by the criterias priority with respect to the goal the anp which is a derivative of ahp based on the benefits opportunities costs and risk values has also been used in many applications multicriteria decisionmaking including project selection both anp and ahp utilize pairwise comparisons to determine weights of the criteria used in order to make a decision these weights can then be used to determine which alternative or option within a selection of potential decision outcomes is the most optimal based on criteria weights alternatively the weights derived from the ahp process can also be applied to other multicriteria decision models unlike ahp the anp has the ability to allow the decision criteria to interact and for the criteria to be affected by the alternatives thereby while anp is more involved mathematically it provides a broader more realistic approach to multicriteria decisionmaking both the ahp and anp models are based on a comparative judgment of the alternatives and criteria since anp dismisses the hierarchical structure associated with ahp it allows criteria to interact with each other after creating the local priority matrix for the criteria which consists of deriving matrix a as previously described for each criteria a supermatrix is formed b ¼ c 1 c 2 c where c n is the nth cluster with criteria or element e ij and each a ij is the local priority matrix as described in the ahp formulation evaluating the relative priority between cluster i and cluster j although this supermatrix allows for influence of every element on every other element if two clusters have no influence on oneanother then a ij 0 while criteria can be grouped into clusters a cluster could also contain only one criterion after determining the local weights using the eigenvector value the global weights are calculated by raising the supermatrix to limiting powers lim k1 b kð3þ raising the supermatrix to compute the limiting priorities allows for the determination of whether the supermatirx is reducible or not this permits for normalization and allows the control criteria to not be dependent on the alternatives unlike ahp the anp supermatrix allows for interdependence between all of the elements in classical ahp applications for project selection all criteria considered in the model are related to the attributes of individual project or grantee the interorganizational communications and the social relationships between organizations can be considered as an additional cluster of evaluation criteria c n in the model in the next section we introduce a set of metrics developed in social network analysis to evaluate the interorganizational communications and the social relationships that are used in the integrated model social network analysis in a social network entities are connected in various ways with various levels of interaction the entity is referred to as a node while the connections between entities are known as links for this empirical example the nodes include organizations in the research for development network and the links represent three different types of connections two common topological metrics in a social network are degree centrality and betweenness centrality given a network g ¼ ðs lþ with jsj nodes and jlj links eqs and represent these two metrics for any node s 2 s c d ðsþ ¼ degðsþ ¼ x j x sjð4þ c b ðsþ ¼ x isj2s r ij ðsþ r ijð5þ where x ij and r ij represent the number of links and the shortest distance of links connecting a pair of nodes ði jþ respectively and r ij ðsþ represents the number of those shortest paths that pass through node s centrality measures can provide useful information about the functioning of the social network for example if an organization has a low betweenness value and a high degree value this organizations connections are repetitive and communication can potentially bypass them with no adverse consequences conversely if an organization or node has a low degree but high betweenness value that organizations ties while few are critical to the overall functioning of the network network analyses can be used to identify the organizations or actors in a network that serve as integral links to that network also known as a key player the key player problem consists of two subproblems node disruption determining the node or set of nodes that if removed would maximally disrupt communication among the remaining actors and node reach determining the node or set of nodes that is maximally connected to all the other nodes given this problem the network analysis results could be used by an organization to increase its reach within a network by becoming associated with the key player identifying the key player in a social network is not computationally straightforward while the key player problem in social network analysis can refer to both node disruption in the network and node reach in the network for the purpose of this study we are only concerned in organizational reach and therefore the latter of the two key player problems utilizing this measure has multiple applications for example an organization could use this in order to identify a small group of other organizations to use as seeds for diffusing new work practices effectively within the network distance weighted reach the value of reach capital that one node holds can be defined as the sum of the reciprocals of distances from the key player s to all nodes this distance from a set to a node outside for our purposes is the minimum distance from any member of the set to the outside node r ¼ 1 n x j 1 d sjð6þ in eq the distance from a node s to node j is represented by d sj the summation includes all nodes and the distance from the node or set of nodes evaluated to a node within the set is defined to be 1 if there is no path connecting node s and node j then the distance d sj is infinite and the reciprocal of an infinite distance is 0 in this setting r is the proportion of all nodes reached by the set where nodes are weighted by their distance from the set and only nodes at distance 1 are given full weight r gives us the quantitative value of reach used to determine the key player according to this metric the centrality measures as well as the distance weighted reach are important attributes of candidate projects which help companies and research organizations in evaluating the candidate projects such that the key players in the social network are identified and the longterm success of the development project can be enhanced the next subsection illustrates the multicriteria anp project selection model that integrates the project selection criteria from sna the multicriteria anp project selection model this study provides two important advances to the literature on project selection with anp models first unlike any previous work this paper utilizes the anp model within a research for development case study second this paper serves as the first example of integrating sna results to an anp model through creating nontraditional criteria in order to allow for sna results to aid development work we propose three basic stages identify the criteria to be used in the model sna computations and anp computations evaluation of the alternatives and determination of final rank in the first stage of fig 1 the decisionmaking team determines the criteria for which the alternatives will be evaluated in a traditional anp model the decisionmaking team would proceed directly to anp calculations after determining the criteria and decision hierarchy in this model stage 2 represents the application of sna computations which is not included in previous anp models according to the literature international development program success is tied to social relational aspects including communication trust interorganizational collaboration and stakeholder participation this articulates the need for stage 2 which strengthens the traditional project selection techniques utilized in stage 1 and stage 3 finally stage 3 represents the convergence of sna results with anp calculations which allows for the determination of the final rank in this empirical study the anp model represented by the supermatrix b ie eq is modified to include both traditional anp criteria and sna criteria b ¼ a 0 0 d 2 6 4 3 7 5ð7þ where the matrix d includes all the social relationship attributes presented in the previous section since both a and d represent criteria they are still compared utilizing pairwise decisions in order to articulate the differences between these criteria and stages four decision hierarchy trees described in section 24 were used in this study as described by eq we assume that the various criteria do not interact with each other however it is important to note that in a broader multicriteria decision model it would be conceivable for decision makers to choose to allow for criteria interaction identification and hierarchy of criteria in proposed model criteria to be considered in the selection of projects are determined by previous literature for project selection as well as new sna criteria summarized into table 1 eleven criteria and ten alternatives were used in the evaluation process calculated by using the anp method criteria c1c5 are generic project selection criteria selected to represent traditional project criteria used in previous literature criteria c6 c7 c8 c9 are social network criteria calculated based on sna related to the social network structure or link attributes criteria c10 and c11 are related to the organization properties or node attributes of the social network the alternatives are different organizations from an actual international development social network these organizations represent project proposals submitted to a donor organization decision making team for international development funding in order to determine the benefit of introducing additional sna criteria four different hierarchy trees were evaluated in addition all 11 criteria are categorized into benefit opportunity cost and risk categories although these criteria were categorized according to the types listed in table 1 different decision makers may choose to categorize criteria in other ways for example organization experience and author track record could be categorized as opportunity criteria if the decision making team viewed them as a positive benefit instead of a potential risk this traditional benefit cost opportunity and risk model allows for the development of two different hierarchy trees utilizing all 11 criteria fig 2 represents multiple scenarios created in stage one the group working stage of the proposed model four decision networks are constructed in order to model likely scenarios for the priorities of a hypothetical donor organization in the first case the donor organization determines that only social network criteria for each alternative organization should be utilized in evaluating the project proposals this articulates a case where a donor organization project selection team believes that the network relationships of the recipient organization are the only important factors in the overall success of the project in the second and third cases all eleven criteria were used the shaded boxes in the second case were weighted at a ratio of a to the unshaded boxes b and a þ b ¼ 1 this is a commonly used weight where a donor organization project selection team ranked the benefits and opportunities as more important than the costs and risks case three utilizes all criteria with equal weight the cases 2b and 2c articulate two typical implementation strategies for the proposed model in the final case the decision network included traditional project selection criteria only this represents the current status of ahpanp modeling for project selection which does not integrate any social network analysis criteria to evaluate the benefit of introducing additional sna criteria to anp model the proposed model is evaluated using data collected from a mekong basin international development network in the next section empirical study and results mekong basin international development social network in order to complete stage 2 of the proposed model a mekong basin international development social network was created the mekong river located in southeast asia is the 10th largest river in the world with a length of 4909 km this transboundary river spans six different countries with headwaters that originate in chinas yunnan province then flow south into burma lao pdr thailand cambodia and ultimately outflow from viet nam into the south china sea the lower mekong basin comprised of the basin sections within burma thailand laos cambodia and viet nam is the most populous and wellstudied region within the mekong river basin and is home to over 60 million people this region is in a transitional period of development as several countries within the basin are pursuing large scale hydropower dam projects these infrastructure projects will change the natural water flows of the mekong and could potentially present challenges to water and food security for mekong basin citizens due to the environmental complexity research for development activities has been highly regarded by many large international development organizations the network model of the organizations in the mekong river basin working in research for development related to water and food security was created using a survey this survey was sent to 101 known organizations whose contact information was provided by a large international research organization a list of these organizations was used to create a structured format for survey questions because a list of over 100 organizations may overwhelm a survey respondent a subset of that list was used for the survey 62 organizations that appeared to be most involved with the mekong river basin according to their webpages along with 8 spots where fillintheblank organizations could be written for a total of 70 selection choices were used in the online survey sent to organizations involved in research for development activities in the region the 8 openended spots were stratified by sector government ministries nonprofitnongovernmental organizations private companies universities and other government organizations the survey respondents were asked to explain the level strength of linkage between their organization and the partner organization formal other organizations that you formally report to collaborate with or work with on watershed management in the mekong informal other organizations that you have an informal professional relationship with and familiar other organizations that you are familiar with but have had no formal or informal interactions with the three options enable the building of a network with different linkage levels between nodes an overall survey response rate of 59 was obtained as shown through fig 3 the network produced included 109 unique organizations and 901 different organizational links of varying levels within fig 3 the nodes are shaded according to the organization type and the size of the node is associated with the size or scope of the organization additionally the strength of linkage is associated with the darkness of the line the labels of each organization have been removed in order to provide anonymity to survey respondents in order to complete the project selection model ten alternatives were selected from this social network these alternatives represent real organizations within the mekong river basin research for development social network these organizations were chosen to represent a wide array of organization type scope and location in the network that are likely candidates for submitting a project proposal for development funding utilizing the key player approach the social network results for each of the 10 alternatives are articulated in table 3 reach degree and betweenness were calculated using eqs since the actual values of these metrics are relative to the social network under examination the rank of each value according to the overall network of 109 organizations is displayed for easy comparison between organizations the reach and degree rankings only vary slightly from one another this implies that these centrality measures are correlated with one another however there is variation in the rankings for degree centrality and betweenness centrality for example alternative a8 has a degree rank of 8 which is high but a betweenness ranking of 21 this implies that although alternative a8 is highly connected the connections are not unique and therefore may not be as important to the overall functioning of the network as an organization that has a high degree and a high betweenness ranking a donor organization such as the world bank us agency for international development or the bill and melinda gates foundation may utilize this information in order to garner further connections within the network of organizations the actual values of reach degree and betweenness were utilized in the anp model but since these values are relative to each different social network the ranks provide a more clear illustration of the influences each alternative may have on the overall anp outcome furthermore as shown next through the project ranking analysis the proposed multicriteria anp project selection model combines these sna results with anp in order to evaluate the differences between traditional anp applications and the addition of stage 2 in the proposed model anp results in order to complete stage 3 of the proposed model the superdecisions software was utilized for the criteria network and the pairwise comparison of criteria fig 4 shows the theoretical network structure of the anp model in superdecisions as shown through the figure the social network criteria are designated in black while the traditional project selection criteria are designated in white this represents two of the four cases analyzed for comparison between criteria in the superdecisions software each primary factor was created with a subnetwork of those influential criteria traditionally the pairwise comparison of criteria can be derived from a survey of the decisionmakers values but for the purpose of this empirical example random pairwise comparisons are made for the four hierarchy cases previously articulated the cases in table 4 show only one application of the potential pairwise comparison the criteria were compared on a 9point scale which is commonly utilized in questionnaire procedures if actual decision makers were contributing to the model formulation since decision makers were not involved a random number generator from the r statistical software was used to choose the 19 ranking of each criterion comparatively in practice these pairwise comparisons would be formed by the decision makers but here they are randomly generated to show four specific cases among potentially unlimited combinations of methods for prioritizing the set of projects in addition to ranking the criteria each alternative was scored from 19 with respect to the specific criterion the weights of the criteria derived from the final limit matrix were then used to calculate each project final score these scores are for demonstration purposes only and were not derived from real data as previously described tables 5 and6 further articulate how the alternatives for funding an organization project vary with the different cases illustrated in fig 2 when only sna criteria are analyzed as an organization might do in order to increase its reach within the network the results indicate the best organization to fund would be organization 26 then organization 5 and so on in case 1 sna is the only influencing factor in project selection so the projects selected are all from organizations with high sna criteria scores if the donor organization was only concerned with increasing its reach within their social network by utilizing project selection it would choose to fund alternative a1 using case 1 cases 2 and 3 show that when sna is integrated with traditional project selection criteria the results can vary as shown in case 2 the top five alternatives still have high sna scores because most of the benefit and opportunity criteria which has a higher weight are related to the sna criteria case 3 articulates the model which most evenly prioritizes the dual goals of selecting the best project while also increasing the donor reach in a traditional anp project selection model a donor organization would select a project to fund without considering the social network criteria the results show that the donor would fund the project proposal from alternative organization 71 then organization 68 and so on since the top alternative does not have an important role in the social network for the mekong basin the donor organization would be funding an organization without key social connections that lead to program success hence using a traditional anp model would produce significantly different results than modeling a project selection process with sna criteria discussion and conclusion this study proposes a multicriteria anp project selection model for combining social network topological measurements with traditional project selection criteria in order to maximize the outcome for the donor organization combining two nontraditional fields allows for the opportunity to fund and deploy development projects that are more successful than many underway today reducing the failure of development work will strengthen the opportunities to bring millions of people out of poverty worldwide as shown through the empirical study the proposed model can incorporate social network metrics in order to aid complex decisionmaking processes such as project selection for donor organizations from the evaluation of results we are able to derive which grantee organization would increase the donor organization connections within the network while optimizing project selection criteria the study also articulates the influence of various social network topological measures such as reach degree and betweenness the study approach illustrates several unique features which contribute to the depth of knowledge in social network analysis and multicriteria decisionmaking with anp models first integrating social network analysis in this way allows for including both link data traditionally captured in topological social network analysis as well as node data about the organizations themselves which is not often captured and is independent of the link connections second articulating social network features as criteria in an anp model allows for optimizing two traditionally separate goals project selection and organizational connections within a real network finally this work provides an approach to integrate two analytical techniques which increases complexity yet still remains accessible to managers and researchers in organizations worldwide in a real world project selection process decisionmakers would provide value judgments that indicate how the pairwise comparisons of criteria should be done in order to achieve the weights of criteria this project selection model utilized random values for the information about the proposed project as well as the pairwise comparisons of criteria however in reality there would be data for the project alternatives being evaluated additionally the social survey construction can only be as complete as the response rate allows the achieved response rate of 57 is considered acceptable for an online survey since it is representative of the overall sample despite these issues we show how utilizing a traditional anp project selection model without the sna completed in stage 2 could lead to a decisionmaking team selecting an organization without the proper social connections that lead to successful development interventions this study presents a framework and an example model of how employing nontraditional social network criteria could be accomplished another methodological approach could include integrating fuzzy logic into the final ranking procedures of anp additionally time variation is currently an important segment of social network research this work only evaluated a social network at one point in time but if social networks were evaluated over time different conclusions relative to the importance of organizational relationships may unfold within the field of social network research identifying the possible interactions between the anp criteria and sna criteria could contribute to the development of a more comprehensive multicriteria decision model these techniques are also perfectly suited to be applied to project evaluation after a decision making team chooses and funds a particular alternative if data was available which quantified the success of project outcomes this model could be validated and used in broader approaches note the weight column is the final limit matrix

the social relationships between development agencies nongovernmental organizations private companies and other groups working on development projects play an important role in the overall success of projects however traditional project selection and prioritization processes ignore the organizational relationships this paper proposes to integrate social network analysis into multicriteria decisionmaking processes to enhance the effectiveness of project selection a set of topological metrics of social network are used to quantitatively measure the organizational relationships and integrated into the analytic network process anp to form a multicriteria anp project selection model utilizing empirical social network data of a water and food security research for development network in the mekong river basin we investigate the effectiveness of the proposed model the results show that it will offer companies government agencies and other donor organizations the opportunity to prioritize strategic network goals simultaneously with research and development priorities and help companies and research organizations to increase their impact and reach within networks

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introduction adolescence is a phase of growth biologically psychologically and socially functional and structural changes in the brain are paralleled by psychosocial development in this period adolescents need balancing especially between emotions and cognitions understanding the existential value of self improving selfawareness choosing goals in life being independent of the family emotionally maintaining psychological and emotional stability against environmental stressors and establishing healthy relationships with others if these characteristics of adolescence are ignored there is a potential risk of many unhealthy behaviors one of which is intentional selfinjury due to its increasing prevalence nonsuicidal selfinjury was included in the diagnostic classes of the fifth edition of the diagnostic and statistical manual of mental disorder nssi is defined as intentional and deliberate body tissue injury with no suicidal intention including selfhitting cutting or burning nssi does not include unintentional and indirect selfinjury suicidal attempts and socially acceptable behaviors such as piercing tattooing or religious practices currently there are at least 33 terms related to selfinjury such confusion and uncertainty in the definition of variables affect the identification and exploration of the nature of selfinjurious behavior there are several models for classifying selfinjury according to one of these models selfinjury is divided into two categories stereotypic selfinjury prevalent in pervasive developmental disorders and psychotic symptoms and impulsive selfinjury occurring as impulsive behaviors in an alternative classification selfinjury behaviors are divided into direct and indirect classes the former refers to intentional actions that directly cause harm to the body and the latter refers to behaviors that do not intentionally and directly injure body tissue in their serbian youth sample kostić et al found the most common method of selfinjury to be cutting followed by severe biting and scratching one of the questions raised about nonsuicidal selfinjury is how to determine its relationship with suicide attemptsnonsuicidal selfinjury and suicide are distinguishable concerning intention methods chronicity lethality cognitions responses outcomes prevalence and demography studies have shown comorbidity among these two behaviors even though they are regarded as independent and different nock et al reported a total of 70 of adolescents involved with nssi have a lifetime suicide attempt while 55 have multiple suicide attempts it is alarming that those who engage in nssi are at increased risk for attempting suicide and nssi is one of the main predictors for the next suicide and selfinjury attempts baseline nssi history and hopelessness are significant predictors in the most parsimonious model predicting time to incident suicide attempts according to these results a significant overlap is observed between suicide attempts and nssi studies indicate that the rate of selfinjury behaviors in adolescents is prevalent across cultures for instance muehlenkamp et al found an 18 lifetime prevalence for samples across the globe whereas monto et al found a 177308 prevalence in adolescent girls and a 64148 prevalence in adolescent boys in the united states plener et al found a 31 lifetime prevalence in the german population tang et al found a 122 prevalence in chinese adolescents and gandhi et al found a 21 prevalence in adolescents of dutchspeaking part of belgium these studies highlight the prevalence of nssi across diverse populations across cultures nssi tends to emerge during early adolescence according to a systematic review of longitudinal investigations on nssi the peak nssi prevalence is 1516 years kostić et al examined nssi behavior among adolescents in southeastern serbia this study which utilized a sample of 50 adolescent girls and boys aged 1318 years demonstrated an average age of onset of 1412 years for nssi gandhi et al found the probability of age of onset peaked around the age of 1415 years in dutch belgium adolescents a study of a sample of caucasian african american asian and biracial adolescents identified the average age of nssi onset was 1390 years gender disparities in nssi are of interest to researchers and clinicians alike a study of 15to 16yearold adolescents in australia belgium england hungary ireland the netherlands and norway shows that girls selfinjure at a rate of almost double that of boys and in four out of seven countries at least one in ten girls has selfinjured within the past year based on a metaanalysis conducted by it is more likely for female youth and adults to engage in nssi compared to males intentional selfinjury is a common and often veiled issue in adolescents particularly in females indicating differences and similarities globally to understand selfinjury behaviors in adolescents it is important to know why a particular behavior occurs at a particular time under a particular condition and by a particular individual adolescent selfinjury behaviors are influenced by individual social and cultural factors forrester et al have indicated a significant negative relationship between selfesteem and selfinjury their results revealed that selfesteem is lower in people who experience nssi than others who do not selfinjure further baldwin et al studying 2232 english children from birth to 18 years old indicated that the risk of selfinjury increases in survivors of abuse neglect sexual assault domestic violence peer or sibling bullying cyberbullying and interpersonal crime layegindhu and schonertreichl found that adolescents who selfinjure report significant increases in antisocial behaviors emotional distress anger problems and healththreatening behaviors as well as decreased selfesteem the results of this study highlight the importance of emotion in nssi although research on selfinjury has increased rapidly in recent years more issues are still to be identified and explored in more depth models of nssi offer a means through which to understand its emergence and how it sustains across time intentional selfinjury is described by the experiential avoidance model as a way of escaping from or avoiding undesirable emotional experiences through negative reinforcement although applicable in some cases this model provides a narrow explanation of nssi providing a more expansive conceptualization nock and prinstein proposed a fourfactor theoretical model with two dimensions to explain nssi firstly according to nock and prinstein nssi is either reinforced intrapersonally and automatically or socially secondly nssi is reinforced either positively or negatively this model provides some support for nssi as a learned behavior which might presume that the behavior can be altered or unlearned researchers have also explored the functions of nssithe purposes it serves for those who selfinjure klonsky and glenn identified 13 functions of nssi which apply to regulate emotion establish interpersonal boundaries punish oneself for perceived flaws or mistakes care oneself avoid dissociation prevent suicide seek sensation build peerbelonging influence others interpersonally increase toughness show distress get revenge and achieve autonomy clients may report multiple functions of nssi and those functions can change across time emotionaffect regulation is a commonly reported function of nssi as such much attention has been given to understanding emotion alexithymia and emotion regulation as they pertain to nssi research indicates that alexithymia is a multidimensional deficit in emotion recognition and regulation alexithymia includes four main aspects difficulty identifying and describing subjective feelings trouble differentiating between feelings and the physical sensations of emotional arousal limited imaginative processes and an externallyoriented cognitive style a metaanalysis showed significant positive relationship between alexithymia difficulties identifying feelings difficulties defining feelings and nssi emotion regulation skills are divided into six subskills including emotional acceptance emotional awareness goaldirected behavior during the emotional experience impulse control access to emotion regulation strategies and emotional clarity deficits in emotion regulation skills have been implicated in nssi by both theory and research research shows that nssi is performed as an emotion regulation as it often decreases the experience of negative emotion interventions have demonstrated effectiveness in reducing nssi involve a focus on emotion regulation skills diverging slightly from affect regulation as a primary function of nssi lloydrichardson et al found that trying to get the attention of someone exercise control over a condition and prevent negative feelings are the main reasons for nssi preventing negative feelings might be akin to a form of affect regulation thus highlighting the important role of emotion in nssi examining the functions nssi serves for each person is fundamental to therapeutic intervention this process is called a functional analysis of nssi however it is important to note that due to the relationship between nssi and alexithymia people who selfinjure may find it difficult to identify the functions nssi serves for them the prevalence of selfinjury behaviors among adolescents is concerning there is limited information on the lived experience of nssi and factors that influence nssi from the adolescent perspective therefore the present study using a qualitative research method aimed to investigate and identify the nature and factors related to selfinjury behaviors with no suicidal ideation among iranian female adolescents literature review research on nssi has examined the etiology of this behavior from different perspectives including developmental intrapersonal and social factors additionally the literature supports a coping function of nssi in which nssi might actually serve an antisuicide function although various factors may contribute to the development of nssi the interaction of factors may best explain the emergence of this behavior nock integrated theoretical model suggests an interaction of etiological factors such that both intrapersonal and interpersonal factors contribute to the development of nssi danger of nssi is increased by factors that contribute to problems with emotion regulation or interpersonal relationship and by special factors that influence the decision to use nssi rather than some other behavior to serve these functions psychological psychiatric familial cultural and social factors as well as genetic vulnerability are major contributors to selfinjury emotion plays an important role in the experience of selfinjury edmondson et al found that one of most common reasons for nssi is distress further depression and anxiety are related to selfinjury during adolescence for many people who selfinjure nssi is applied to deal with stressful adverse affective states particularly depression anger and mixed emotional conditions nssi is related to various internalizing and externalizing situations according to chapman and dixongordon anger is the most commonly reported emotion preceding selfinjury and following selfinjury a positive emotional shift characterized by relief and diminished anger is commonly experienced a study by madge et al in secondary schools in belgium the united kingdom hungary ireland the netherlands norway and australia demonstrated that increased selfinjury is associated with high levels of depression anxiety impulsivity and low selfesteem the researchers stated that psychological characteristics and stressful life events reinforce adolescent selfinjury and that these factors are more severe in girls emotional regulation may also affect selfinjury based on a study of a sample of female students limited access to effective emotion regulation strategies and emotional disclarity can predict nssi in further research on hospitalized adolescents with different psychiatric diagnoses a significant inverse relationship is reported between selfinjury and emotion regulation alexithymia and rumination are appeared to be the robust factor in predicting selfinjury the role of coping in nssi has also drawn attention chapman and dixongordon research on the emotional antecedents and consequences of nssi exemplifies the coping functions of selfinjury further a study by borrill et al indicated that people who selfinjure tend to score significantly higher in maladaptive coping styles those who do not report nssi moreover wan et al suggest that in order to prevent nssi in adolescents reducing negative coping styles in girlsboys and improving positive ones in girls with negative childhood experiences might be helpful studies also suggest that both behavioral and cognitiveaffective indicators of interpersonal problems predict nssi onset edmondson et al highlight the role of interpersonal factors in nssi poor relationships in the form of adverse interactions in close relationships and lack of social support and history of sexual abuse are risk factors for selfinjury people who engage in dysregulated behaviors such as nssi commonly report adverse family environments many studies show the variable of family functioning significantly predicts nssi family communication patterns specifically conversation orientation has a positive correlation with lifetime nssi behaviors but not current nssi behaviors and competence in communicating increases nssi behaviors decrease in addition alexithymia mediates the impact of communication skills on nssi behaviors parental harsh punishment low parental monitoring and poor quality of attachment to parent predicted new onset of nssi moreover oldershaw et al indicate that parents have challenges in understanding resolving and overcoming adolescent selfinjury behavior they need support and advice to manage selfharming behaviors the role of interpersonal factors in nssi is noteworthy particularly regarding social contagion peer factor predicted new onset nssi a study by prinstein et al suggests the role of peer socialization in the development of nssi in adolescent females after controlling for depressive symptoms as a predictor the researchers found that adolescents nssi was associated with increasing perceptions of their friends engagement in depressiveselfinjurious thoughts and behavior further in a systematic review social contagion related nssi was found in 16 studies according to this review the initial involvement with nssi in particular might be extremely affected by social contagion whereas the nssi preservation is very likely to be associated with intrapersonal functions developing over time media and contagion affect selfinjury dramatically with the internet playing a major role in contemporary role jacob et al have indicated that images rather than textual interactions are the main reasons for using the internet for selfinjury images evoke a physical reaction and motivate the action seeing pictures online plays a major role in the selfinjury of many young people increased attention is being given to social and interpersonal influences related to nssi social support and connection are protective factors in some african american and hispanic youth studies should concentrate on improving the adolescents sense of positive identity and connection to parents and prosocial friends method the present study utilized a qualitative approach to capture participants perception and experience of selfinjury from a phenomenological perspective a qualitative approach is appropriate for this study because qualitative research generally seeks to examine individuals in their natural environment to examine how their behaviors and experiences are formed by the contexts including the social cultural physical and economic in which they live qualitative research allows the researcher to understand the meaning participants assign to their experience using grounded theory the researcher was able to gain understanding of participants lived experience of selfinjury and generate a theorymodel through which to conceptualize their experience research team and researcher reflexivity statement this manuscript is based on the phd dissertation of first author the research team included the first author second author and two advisor professors and the fourth author phd in family counseling and associate professor in university of hormozgan because the first author is a school counselor she had some clinical experience working with adolescents who engaged in nssi the second author supervised the research work analyzed the contents of interviewees and assisted the research team in the coding process advisor professors third and fourth authors participated in coding process reviewing the extracted codes and modifying them if needed all team members had a relative high knowledge about nssi which could contribute to bias in the coding process therefore issues of bias were discussed during coding meetings and multiple measures were taken to increase trustworthiness participants and procedure the statistical population included adolescent females aged 1315 years in shiraz iran the target individuals were identified using purposive sampling the sampling design was on the basis of the researchers opinion about who would offer the best information to achieve the goals of the research the primary researcher is a school counselor and works in schools she identified the sample through her place of employment participation was voluntary as described below the inclusion criteria for the study consisted of the following adolescent age of 1315 years female gender and a history of at least one episode of nssi within the past year data saturation determined the sample size in analyzing the data the category of complete concepts and the relationship between the categories were well defined and no new codes were extracted from the data analysis thus data saturation occurred this goal was achieved by conducting 20 interviews data sources semistructured exploratory interviews were performed to collect data one of the major datacollection methods for qualitative research is interviews which allow for collecting rich data from individuals in different roles and circumstances semistructured interviews fall somewhere in between those of structured and unstructured they involve using certain preformulated questions however the interview protocol is not adhered to strictly rather during the interview new questions can arise which are welcomed in the semistructured interviews the interviewee is provided with an opportunity to add central insights that emerge during the conversation while formerly organized questions offer some focus twelve points stated by mcgrath et al were followed in the present research regarding the development and implementation of interviews identify when qualitative research interviews are appropriate prepare yourself as an interviewer construct an interview guide and test your questions consider cultural and power dimensions of the interview situation develop rapport with your respondents remember the researcher is the data cocreator talk less and listen more allow yourself to adjust the interview guide be prepared to handle unanticipated emotions transcribe the interviews in good time check the data and initiate analysis early based on the indicators identified in the research literature the interview protocol was compiled and provided to the supervisors and consultants for review the interview protocol consisted of ten questions regarding participants experience of nssi including information related to frequency functions interpersonal effects and coping after modifying and confirming the interview protocol the interviews were conducted this research project was approved in the ethics committee of hormozgan university of medical sciences at the beginning of the interviews the research purposes procedures benefits voluntary nature of participating and confidentiality were stated to the participants the researcher confirmed participants understanding of their right to withdraw from the investigation at any time and in any manner further a signed informed consent form was obtained from the participants the duration of each interview was 45 to 60 min depending on the circumstances and participants tolerance for discussing selfinjury and interest interviews were recorded and then transcribed on paper data analysis data analysis was performed according to the grounded theory approach as described by corbin and strauss they offered a thorough procedureoriented method for coding including open axial and selective coding phases open coding involves breaking down analyzing comparing conceptualizing and classifying data open coding is the impressionistic method by which data is analytically decomposed its aim is to give new perspectives to the researcher by breaking through conventional ways of thinking about phenomena represented in the data or interpreting them this puts together conceptually similar eventsactionsinteractions to create categories and subcategories a qualitative research code is most often a word or short phrase that symbolically attributes to a summative prominent essencecapturing andor evocative attribute to a segment of languagebased or visual data in the present study this phase was initiated by the researcher coding paragraph by paragraph line by line phrase by phrase or even word by word to identify data that stood out as meaningful open coding therefore was the extraction of central concepts and initial codes in axial coding categories are related to their subcategories and the relationships are tested against data also further development of categories takes place and the researcher continues to look for indications of the categories through the coding paradigm of conditions context strategies and consequences subcategories are related to a category during the analytic process the analyst can draw upon previous experience to think through the conditions all hypothetical relationships proposed deductively during axial coding must be considered provisional until verified repeatedly against incoming data deductively arrived at hypotheses that do not hold up when compared with actual data must be revised or discarded a single incident is not a sufficient basis to discard or verify a hypothesis to be verified a hypothesis must be indicated by the data over and over again an unsupported hypothesis must be critically evaluated to determine if it is false or if the observed events indicate a variation of the hypothesis in this study the codes gained from the prior phase were classified or divided into subclasses and main classes the third phase selective coding deals with settling on the main class relating it to other classes confirming the relationships and removing any incomplete classes selective coding is the process by which all categories are unified around a core category and categories that need further explication are filledin with descriptive detail the core category represents the central phenomenon of the study it is identified by asking questions such as what is the main analytic idea presented in this research if my findings are to be conceptualized in a few sentences what do i say what does all the actioninteraction seem to be about how can i explain the variation that i see between and among the categories therefore in the present work during selective coding the researcher attempted to find relationships between classes to formulate a theory of adolescent selfinjury validity and reliability in the organizational field reliability and validity of research and its results are central factors in determining the research quality no common standards for determining the validity of qualitative studies are recognized due to differences in their approaches and methods as qualitative research should not be the results of a single test or a phase in the research they should follow a systematic validity approach in qualitative studies validity may have various meanings including appropriateness trustworthiness rigor and even quality being defined in different terms in the present study the following methods were used to achieve validity and reliability first interviews were carefully recorded and transcribed in detail which allowed for accuracy of the original data prior to interpretation through coding second the researcher used member checking to verify the analysis the data analysis and results were presented to a number of participants and their reactions were used for results validity in this regard the participants did not agree on the meaning units related to the concepts of anxiety peer inhibition judgment of others and blame and after discussing each of the disputed categories the cases were modified the rest of the categories were approved furthermore in open coding the participants checked the units of meaning and according to their reactions corrections were made in the wording of units in the axial coding the results was approved by all but in the selective coding participants declared to state the family as the most important factor which was modified third researcher reflexivity was utilized wherein a researcher selfreview was performed repeatedly during the data collection and analysis processes and fourth the contents of the interviews and the coding were provided to three experts for review who provided an audit of the coding combined these measures were intended to reduce the potential influence of research bias on data analysis results data analysis was performed so that in the first stage the texts were read one by one and the concepts contained in it were identified in this step open coding a conceptual code was assigned to each smallest significant unit of textual content thirtytwo concepts were observed which were named according to the researchers inference and closely related to the data the open coding continued until no new information was obtained from the texts and it was ensured that all the concepts in the texts came under the title of a code appendix b presents the results of open coding including the code enumeration the codes are selfdeprecation identity religion feeling lonely feeling misunderstand temporary catharsis depression anger anxiety hate repression of emotions coping strategy attention seeking manipulative behavior imitation interpersonal pressure prohibition interpersonal difficulties communication with family disagreement or separation from parents disagreement and separation from boyfriend abuse others reaction others judgment fear of hurting others picture video music blame fear habitation and working and financial issues in the second phase axial coding several concepts or codes with a common meaning and theme were named under a more comprehensive title or category these categories were considered subcategories axial coding has a higher abstraction and searches for patterns embedded in the text therefore in this process a deeper description of the text was obtained and finally the subcategories were summarized in the main categories in the current work axial coding results are presented in appendix c the subcategories are thoughts emotions behaviors and social factors individual or psychological factors include any factor affecting nssi that may be related to one of the respondents individual characteristics for instance the interviewees response which attributes nssi to feeling lonely is considered as an individual factor individual or psychological factors are divided into three subsets thoughts emotions and behaviors based on the agreement between the authors the factor or category of thoughts refers to the cognitions and beliefs related to nssi which can trigger such an action on the part of the adolescent the category of emotions refers to feelings related to nssi emotions that trigger or reinforce behaviors that leads to nssi the category of behaviors includes behaviors that are related to selfinjury actions these behaviors can include both selfinjury actions and behaviors that facilitate or prevent these actions as observed the main role is assigned to emotions in adolescent selfinjury individual or psychological factors mental activity produces thoughts which consist of an aimoriented flow of concepts and relations resulting in a realityoriented conclusion thinking enables people to interpret represent or model the world they experience thus predicting worldrelated affairs based on the results of the interviews in this research adolescent selfinjuryrelated thoughts include three cases selfdeprecation identity and religious beliefs cabanac stated there is no consensus in the contexts on a description of emotion the word is taken for granted in itself emotions are biological and mental states that lead to psychological and physical changes affecting peoples behavior in this research participant statements revealed that feeling lonely misunderstood depressed angry or hateful can contribute to selfinjury in adolescents as can repression of emotions moreover although the feeling of emptiness and temporary relaxation after selfinjury can be a positive reinforcement for selfinjuring anxiety after selfinjury can be a deterrent from a behavioral perspective in this research selfinjury is associated with the concepts of coping attention seeking and manipulative behavior both of which reinforce selfinjury adolescents in this sample report harming themselves because they feel under pressure and selfinjuring is the most effective means they have found to cope with the pressure adolescents in this sample may also think that they can attract the attention and love of others or otherwise get what they want by engaging in nssi social factors based on an analysis of the data in this study the social factors are associated with adolescent selfinjury based on the agreement of the authors social factors include any factor affecting nssi that may be related to the respondents social environment that includes family factors peer factors communication with different gender communication with others media and cyberspace school and economic factors for example the interviewees response which attributes the nssi to divorce or parental conflict falls into the category of social factors according to the results of this study relationships with peer groups can be both motivating and inhibiting imitation interpersonal pressure and interpersonal difficulties are ways that peer groups affect adolescent selfinjury in this sample as motivating factors prohibition is a way that peer groups affect adolescent selfinjury as an inhibiting factor adolescents in this sample reported that the type of relationship they have with their family is a very important and determining factor in this research tensions in the family divorce rejection and lack of communication skills can cause stress and selfinjury in adolescents additionally results of communication with different gender in the form of infidelity or traumatic sexual experiences can cause stress and thereby trigger adolescents selfinjury in this sample the factor of communication with others is related to selfinjury outcomes participants in this study reported that their selfinjury causes others to feel upset and angry and others blame adolescents for nssi however participants also reported feeling concerned about others negative perceptions and judgments about them which contributes to participants tendency to hide their wounds so that others do not discovery their selfinjury seeing photos and videos or listening to music in cyberspace can also be a motivating factor or trigger for selfinjury participants also reported school factors as results of selfinjury which might include issues such as being reprimanded or intimidated by school staff further participants discussed economic factors including unemployment and income as stressors that contribute to their selfinjury summary in general the results of this study showed that nssi in adolescents is complex and a multidimensional phenomenon influenced by various factors simultaneously among the influential individual factors the role of emotions is fundamental in particular depression anger and repression of emotions tend to lead to selfinjury and temporary catharsis can be an important reinforce for subsequent selfinjury behavior among the influential social factors the role of the family is prominent almost all participants reported communication problems with family members especially parents in most cases despite a healthy relationship between parents together and an appropriate atmosphere in the family conflict or disagreement is formed between parents and adolescents due to the application of special parental restrictions due to the puberty characteristics of adolescents therefore it seems that among all individual and social factors familyrelated issues play a significant role in the development and perpetuation of selfinjury within this sample discussion the results of this study demonstrate that factors affecting nssi are divided into two general categories of individual or psychological factors and social factors among the individual and social factors the role of emotions and the family are important respectively adolescents relationship with their family can be a motivating and maintaining factor for nssi nock integrated theoretical model klonsky and glenn motives of nssi and han statements are consistent with the results of this study regarding the impact of individual and social factors on nssi nock expressed that both intrapersonal and interpersonal factors are effective on nssi klonsky and glenn identified 13 functions of nssi that categorized into interpersonal and intrapersonal functions han stated selfinjury in adolescents is influenced by individual social and cultural factors the results of our research on the effect of individual factors in adolescent nssi are consistent with previous studies the factor of thoughts involved selfdeprecation identity and religion earlier studies have suggested the role of low selfesteem in nssi that are consistent with selfdeprecation taliaferro et al identified that a sense of positive identity prevents nssi which is consistent with the results of the present study regarding the role of identity in nssi borrill et al mentioned that rumination in nssi is important and it is consistent with the result of this study regarding the role of thoughts in contributing to nssi the results of the present study demonstrate that feeling lonely misunderstood depressed angry hateful or repression of emotions contribute to selfinjury the feeling of emptiness and temporary relaxation after selfinjury can be a positive reinforcement for selfinjuring whereas anxiety after selfinjury can be a deterrent the research literature has pointed to the role of emotional regulation emotion recognition avoiding negative emotions alexithymia emotional dysregulation depression anger and anxiety or stress in nssi regarding the behavioral factors obtained in our study adolescents are injuring themselves in order to cope with pressure attract the attention and love of others andor get what they want this aligns with klonsky et al noted function of nssi to achieve interpersonal influence or communication additional research literature has referred to role of coping styles and attention seeking in nssi the results of current study on the impact of social factors in adolescent nssi are also consistent with previous studies imitation interpersonal pressure and interpersonal difficulties are ways that peers affect adolescent selfinjury in this sample as motivating factors prohibition is way that peers affect selfinjury as an inhibiting factor further the results of this study suggest that tensions divorce rejection and lack of communication skills in the family can cause stress and selfinjury traumatic sexual experiences or rape are significant stressors that were implicated in nssi in the current sample further participants talked about the impact of their selfinjury on others causing their loved ones to become upset and anger and to blame the adolescent engaging in nssi adolescents reported feeling concerned about others negative perceptions and judgments about them participants also talked about seeing photos and videos or listening to music in cyberspace as a motivating factor or trigger for selfinjury additionally they reported that being reprimanded or intimidated by school staff and experiencing unemployment or income issues are stressors that contribute to their selfinjury in earlier studies the social factors include the role of neglect family communication patterns specifically conversation orientation and competence sibling relationships consist bullying family factors like parentchild interactions interparental relationships family dynamics family satisfaction flexibility … interpersonal effects like interpersonal stressors adverse interactions lack of social support … poor relationships with friends and peers socialization effects sexual abuse or sexual violence support social for prevent nssi and media and internet we believe that cultural factors have a major impact on adolescent nssi in particular cultural differences between western and eastern countries can be noted as far as the culture of iranian adolescents is concerned we can refer to cultural influences such as the family parenting system restrictions imposed by culture and lifestyle the type of relationships adolescents have with the different sex iranians attitudes toward emotions and their tendency to suppress and ignore them and religious inhibitions it seems that iranian culture with an emphasis on emotional inhibition has a significant effect on nssi according to the findings of our study emotional factors including emotional suppression or conversely temporary catharsis are closely related to the nssi also the religious context of iranian society and the religious inhibitions emphasized by the family have been effective in preventing the occurrence of nssi however being religious can also exacerbate nssi by creating guilt in adolescents with nssi in consideration of these findings the following implications for counseling practice are noted professional counselors may work with adolescents using cognitive based techniques to address negative or selfdeprecating though patterns that lead to or trigger nssi existential techniques may be applied to address adolescents identity and sense of purpose in life as documented in previous literature and highlighted in the present study professional counselors may also work with adolescents who selfinjure to improve nonharming coping skills utilize problemsolving skills and practice emotion regulation considering the prominent role of social and familial factors in nssi within this sample professional counselors may work closely with adolescents to improve interpersonal functioning and assertive communication skills further adolescents should be supported in attempts to develop or enhance a healthy support system finally when working with iranian adolescent females or clients from traditional cultures where emotional inhabitation is expected crossgender interaction is prohibited andor adherence to religious protocols is expected counselors may help clients with using cognitive interventions acceptance and commitment techniques gestalt interventions and reality therapy interventions from glassers model limitations and implications for further research since most qualitative studies aim at identifying a phenomenon and presenting a theory about it based on qualitative data the generalization of findings to other samples is not possible which can be considered one of the main limitations of this research conducting facetoface interviews is important in establishing communication gaining trust and obtaining information due to the spread of the coronavirus restrictions have been placed on conducting facetoface interviews thus a number of them were conducted by telephone which could have affected the participants interview response based on this research results it is suggested to design interventions that mainly focus on emotional regulation as well as family relationships and functions in adolescents who selfinjure by identifying the function of selfinjury for each adolescent a counselor can more appropriately adapt therapeutic interventions to meet individual needs the findings of this study also help to more elucidate counselors conceptualizations of nssi which included considering it as a functional and adaptive emotional coping skill the current study provides information relevant to the social issues include peers family mediacyberspace and school factors accordingly it is suggested that family counselors and school psychologists in intervention programs address the effects of these factors on nssi counselors may choose to treatment strategies which are rooted in family and school dynamics research with different communities and samples can also be performed finally one of the cultural phenomena different from western societies dedicated to iranian culture is issues related to the relationships with the different sex this is a factor that affects the experience of nssi at a high level and may be a significant area for future research if there was a companion who listened to me and i could confidently tell my feelings without fear i didnt hurt myself why does no one understand me while i understand others im sorry and afraid it will remain in hand and it will be bad for courtship and marriage i am afraid of happening something that my father understands it can get worse i hid it but my mom found out i covered it so that others did not understand first i hid it then my parents understood and blamed me and were upset i wore long sleeves so that others did not understand i hid but the school understood and told my parents i hide from the others because they say how are you and how do you dare the others opinions about me will be negative and it will bother me appendix a see table 1 appendix b see table 2 appendix c see table 3

this study aimed to investigate the phenomenon of selfinjury among female adolescents the research was qualitative and the sampling method was purposive nonrandom the sample size was 20 iranian girl adolescents aged 1315 years who had experienced nonsuicidal selfinjury data were collected through semistructured interviews the data analysis process was performed during three coding steps open axial selective through which the basic codes and categories were identified study results indicate that the main factors in adolescents selfinjury were individual or psychological thoughts emotions and behaviors and social peers family communication with different gender communication with others mediacyberspace school and economic in the former the role of emotions was remarkable while in the latter the family played a key role further results revealed that communication within the family was an important motivating and sustentative factor in adolescents selfinjury the results can help counselors in working with adolescents who selfinjure results can also be used in the development and implementation of treatment plans

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background the risks and realities associated with teenage motherhood are well documented with consequences starting at childbirth and following both mother and child over the life span teenage births result in health consequences children are more likely to be born preterm have lower birth weight and higher neonatal mortality while mothers experience greater rates of postpartum depression and are less likely to initiate breastfeeding 12 teenage mothers are less likely to complete high school are more likely to live in poverty and have children who frequently experience health and developmental problems 3 understanding the risk factors for teenage pregnancy is a prerequisite for reducing rates of teenage motherhood various social and biological factors influence the odds of teenage pregnancy these include exposure to adversity during childhood and adolescence a family history of teenage pregnancy conduct and attention problems family instability and low educational achievement 45 mothers and older sisters are the main sources of family influence on teenage pregnancy this is due to both social risk and social influence family members both contribute to an individuals attitudes and values around teenage pregnancy and share social risks that influence the likelihood of teenage pregnancy 67 having an older sister who was a teen mom significantly increases the risk of teenage childbearing in the younger sister and daughters of teenage mothers were significantly more likely to become teenage mothers themselves 89 girls having both a mother and older sister who had teenage births experienced the highest odds of teenage pregnancy with one study reporting an odds ratio of 51 5 studies consistently indicate that girls with a familial history of teenage childbearing are at much higher risk of teenage pregnancy and childbearing themselves but methodological complexities have resulted in inconsistent findings around parentchild sexual communication and adolescent pregnancy risk 10 a review of family relationships and adolescent pregnancy risk found risk factors to include living in poor neighborhoods and families having older siblings who were sexually active and being a victim of sexual abuse 10 research around the impact of sisters teenage pregnancy has been limited to mostly qualitative studies using small samples of minority adolescents in the united states 511 to our knowledge no previous studies have examined the impact of an older sisters teenage pregnancy on the odds of her younger sister having a teenage pregnancy and compared this effect with the direct effect of having a mother who bore her first child before age 20 by controlling for a variety of social and biological factors and the use of a strong statistical designpropensity score matching with a large populationbased datasetthis study aims to determine whether teenage pregnancy is more strongly predicted by having an older sister who had a teenage pregnancy or by having a mother who bore her first child before age 20 methods setting the setting of this study manitoba is generally representative of canada as a whole ranking in the middle for several health and education indicators 1213 at the time of the 2011 census approximately 12 million people resided in manitoba with more than half living in the two urban areas winnipeg and brandon 14 teenage pregnancy rates in manitoba exceed the national in 2010 teenage pregnancy rates in canada were 282 per 1000 in manitoba the rate was 487 per 1000 15 the manitoba teen pregnancy rates in 2010 were slightly lower than rates in england and wales and the united states 1617 data the manitoba population health research data repository contains provincewide routinely collected individual data over time across space for each family and for each resident health variables are measured continuously from physician claims and hospital abstracts 18 a research registry identifies every provincial resident with information on births arrival and departure dates and deaths created from the provincial health registry and coordinated with vital statistics files given approximately 16000 births annually followup is comparable to that in the largest cohort studies based on primary data 19 previous research using similar data shows the results are not biased by individuals leaving the province or dying information on data linkage confidentialityprivacy and validity of the datasets used have been described elsewhere 20 21 22 children are linked to mothers using hospital birth record information the mother was noted in essentially all cases 23 sisters were defined as having the same biological mother the cohort consists of women who were born in manitoba between april 1 1979 andmarch 31 1994 stayed in the province until at least their 20 th birthday had at least one older sister and had no missing values on key variables in this study teenage pregnancies are defined as those between the ages of 14 and 19 pregnancies prior to age 14 were excluded due to low numbers and for comparability to other studies for this reason families in which at least one sister had a pregnancy before age 14 were removed to address threats of independence when a family had more than one younger sister one younger sister was randomly selected figure 1 over 85 of girls in this cohort were living in the same postal code as at least one older sister outcome teenage pregnancy was defined as having at least one pregnancy between the ages of 14 and 19 a pregnancy is defined as having at least one hospitalization of with a live birth missed abortion ectopic pregnancy abortion or intrauterine death or at least one hospital procedure of surgical termination of pregnancy surgical removal of ectopic pregnancy pharmacological termination or pregnancy or intervention during labour and delivery pregnancy status was determined by icd9cm codes icd10ca codes and canadian classification of health intervention codes in the hospital discharge abstract database 24 appendix 1 presents specific codes used to determine pregnancy status independent variable the independent variables of interest were whether an individual had an older sister with a teenage pregnancy and whether an individuals mother bore her first child before age 20 covariates based on an extensive literature review and availability of information in the database several key variables describing neighborhood maternal and individual characteristics were included 425 covariates measure characteristics in the younger sisters life before age 14 neighborhood socioeconomic status at age 14 was measured by the socioeconomic factor index which is generated using manitoba dissemination areas 26 this index combines neighborhood information on income education employment and family structure these neighborhoods typically include between 400 and 700 urban individuals and are somewhat larger in rural areas neighborhood location at age 14 was divided into urban rural south and rural mid north the maternal characteristic included is marital status at birth of child an individuals number of older sisters was also accounted for three timevarying covariates between birth and age 13 for the younger sister were included in the studymental health conditions residential mobility and family structure change these variables can occur at specific points in time and the timing of their occurrence can differ across individuals mental health is defined using the johns hopkins university adjusted clinical group software this software groups medical and hospital diagnoses over the course of a year into 27 major expanded diagnostic clusters 27 if for 1 year between birth and age 13 the diagnoses an individual received fell into the mental health medc that individual was categorized as having mental health conditions before age 13 residential mobility was measured by at least one residential move between birth and age 13 at least one change in family structure between birth and age 13 was noted as family structure change low educational achievement has been linked to an increased risk of teenage pregnancy 28 the earliest measure of educational achievement available is the grade 9 achievement index which was built on a technique developed by mosteller and tukey using enrollment files course grades and the provincial population registry 2930 as some of the individuals in this cohort experience their first pregnancy before completing grade 9 this covariate is only appropriate for girls having their first pregnancy after their 16 th birthday sensitivity testing was done with this population to determine how strongly educational achievement affected the odds of the variables of interest analytic approach the relationship between pregnancy during ones teenage years and having an older sister who became pregnant during adolescence or having a mother who bore her first child as a teenager is confounded by many measured and unmeasured characteristics we adjusted for these confounding characteristics using 21 propensity score matching 31 two controls were matched with every case as this will result in optimal estimation of treatment effect 32 propensity score matching both enables adjustment for several confounders simultaneously and facilitates diagnostic tests to identify whether the adjustment strategy created comparable exposure groups 31 logistic regression models were used to calculate propensity scores for two responsesthe predicted probability of having an older sister having a teenage pregnancy and the predicted probability of having a mother bearing her first child before age 20 for each model we investigated the comparability of our two groupsthose with and without an older sister having a teenage pregnancy and those with and without a mother who bore her first child as a teenagerusing two diagnostics a kernel density plot verified that the distribution of propensity scores in our two groups overlapped 33 each case was matched to two controls using greedy matching 34 second after matching the balance of the covariates was assessed using standard differences and ttests covariate balance was checked by tstatistics calculated for the standardized differences between cases and controls for each covariate before and after matching any point outside of the two vertical dotted lines signified a statistically significant difference between the cases and controls on that covariate conditional logistic regression analysis of the matched cohorts examined the impact of an older sisters teenage pregnancy and of a mothers teenage childbearing on teenage pregnancy sensitivity analysis helped assess the validity of the assumption of no unobservable confounders and assessed how strong the influence of unobserved covariates would have to be in order to nullify our findings 3536 the lower limit of the 99 confidence interval was used to determine the threshold unobserved covariates would have to reach to void the observed relationship results impact of older sister having a teenage pregnancy table 1 displays the descriptive statistics of the covariates and outcome variables of the girls having an older sister with a teenage pregnancy 404 had a teenage pregnancy this is significantly higher than the 103 teenage pregnancy rate among those not having an older sister with a teenage pregnancy the covariates in general accord with social stratification theory 37 teens with an older sister having a teenage pregnancy were also more likely to have been born to an unmarried mother and have a mother who herself was a teenage mother at age 14 approximately 42 of those whose older sister had a teenage pregnancy lived in rural midnorthern manitoba only 22 of those whose older sister did not have a teenage pregnancy lived in this region at age 14 lower teenage pregnancy was associated with residence in relatively prosperous southern manitoba individuals with older sisters having teenage pregnancies were more likely to live in lower socioeconomic status neighborhood with higher rates of residential mobility family structure change and mental health issues after propensity score matching the final sample consisted of 1873 cases and 3746 controls a total of 1618 cases and 9878 controls were excluded from the analysis tstatistics calculated for each covariate before and after matching to check for covariate balance all covariates differed significantly in the unmatched sample and balanced in the matched sample the final conditional logistic regression model indicates the odds of becoming pregnant before age 20 for those having an older sister with a teenage pregnancy to be 338 times greater than for girls whose older sister did not have a teenage pregnancy impact of mothers teenage childbearing table 2 displays the descriptive statistics of the covariates and outcome variables of the girls having a fig 2 checking covariate balance of older sisters teenage pregnancy status teenage mother 394 had a teenage pregnancy this is significantly higher than the 131 teenage pregnancy rates among those whose mother bore her first child after age 19 after propensity score matching the final sample consisted of 1522 cases and 3044 controls a total of 659 cases and 11890 controls were excluded from the analysis tstatistics calculated for each covariate showed all covariates to differ significantly in the unmatched sample and to balance in the matched sample the final conditional logistic regression model indicates that the odds of becoming pregnant before age 20 for those whose mother had her first child before 3 thus the impact of being born to a mother having her first child before age 20 on teenage pregnancy is much less than that of an older sisters teenage pregnancy sensitivity analysis and limitations with the confidence interval for the first model ranging between 277 and 413 to attribute the higher rates of teenage pregnancy to unmeasured confounding rather than to an older sisters teen pregnancy status that covariate would need to generate more than a 28fold increase in the odds of teenage pregnancy and be a near perfect predictor of teenage pregnancy in the second model the 99 confidence interval was 130 to 189 unobserved covariates would need to produce a much smaller increase in odds of teen pregnancy to nullify this finding although linkable administrative data have significant advantages some important predictors are lacking information on involvement with child and family services and parental use of income assistance have recently been added to the manitoba databases but do not cover the cohort used here while having a teenage mother and becoming a teenage mother have both been linked to involvement with cfs in 2001 less than two percent of children under age 18 were in care 3839 a variable available for a subpopulation is educational achievement which is highly correlated with both involvement with cfs and parental welfare use 40 these two new measures would likely explain little additional variance in teenage pregnancy appendix 2 describes the cohort and propensity score matching for this additional analysis comparing these findings with the original results in table 3 educational attainment is measured using the grade 9 achievement index a standardized measure taking into account the number of courses completed in grade 9 and the average marks of those courses after adjusting for educational achievement the odds of teenage pregnancy for teens with at least one older sister who had a teenage pregnancy were reduced to 248 and the corresponding odds for teen daughters of teenage mothers were lowered to 139 discussion the rate differences of teenage pregnancy were similar for those whose older sister had a teenage pregnancy and for those whose mother bore her first child before age 20 after propensity score matching on a series of variables the odds of becoming pregnant for a teenager were much higher if her older sister had a teenage pregnancy than if her mother had been a teenage mother for both older sisters teenage pregnancy and mothers teenage childbearing the odds in this study are lower than those reported elsewhere this is likely due to the larger sample size more rigorous methods and inclusion of important predictors several examinations of family histories in the literature show older sisters to have the greatest influence on a younger sisters odds of having a teenage pregnancy controlling for family socioeconomic status maternal parenting and sibling relationships teens with an older sister who had a teenage birth were 48 times more likely to have a teenage birth themselves these odds increased to 51 if both the older sister and mother had a teenage birth 11 four older studies estimated the rate of teen pregnancy to be between 2 and 6 times higher for those with older sisters having a teenage pregnancy 41 this work focused primarily on young black women in the united states and controlled for limited confounders none of the previous studies examining the impact of an older sisters teenage pregnancy controlled for mothers teenage childbearing or timevarying factors before age 14 this research probably overestimated the relationship between sisters teenage pregnancy status the mechanisms driving the relationship between an older sisters teenage pregnancy and the pregnancy of a younger adolescent sister have been examined through approaches based on social learning theory shared parenting influences and shared societal risk 41 banduras social learning theory indicates that most human behavior is learned observationally through modeling from observing others one forms an idea of how new behaviors are performed and on later occasions this coded information serves as a guide for action 7 when sisters live in the same environment seeing an older sister go through a teenage pregnancy and childbirth may make this a more acceptable option for the younger sister 11 not only do both sisters have the same maternal influence that may affect their odds of teenage pregnancy having an older sister who is a teenage mother may change the parenting style of the mother mothers involved in parenting of their teenage daughters child may have supervised their children less communicated with their children less about sex and contraception and perceived teenage sex as more acceptable when the older daughters status changed from pregnant to parenting 42 finally both sisters share the same social risks such as poverty ethnicity and lack of opportunities that increase their chances of having a teenage pregnancy 42 having a mother bearing her first child before age 20 was a significant predictor for teenage pregnancy we found daughters of teenage mothers to be 51 more likely to have a teenage pregnancy than those whose mothers were older than 19 when they bore their first child this is quite close to the 66 increase found by meade et al who controlled for many of the same variables except having an older sister with a teenage pregnancy and the timevarying covariates of family structure change mental health conditions and residential mobility meade et al 9 did adjust for school performance in the adjusted subsample the odds ratio reduced to 134 indicating a 34 increase in teenage pregnancy intergenerational teenage pregnancy may be influenced by such mechanisms as biological heritability intergenerational transmission of values regarding family the mothers level of fertility the indirect impact of socioeconomic and family environment through educational deficits or low opportunity or aspirations and directly through the mothers role modeling 43 women bearing their first child in their adolescence are more likely to pass on risky characteristics which could produce negative outcomes in their offspring 44 another mechanism identified as contributing to intergenerational teenage pregnancy is that daughters of teenage mothers have an increased internalized preference for early motherhood have low levels of maternal monitoring and are thus more likely to become sexually active at a young age and engage in unprotected sex 44 the influence of a mothers teenage pregnancy therefore works through the environment created and parenting style assumed as a result of a mothers teenage childbearing the use of administrative data to conduct health services research has some significant advantages and limitations administrative data from a large birth cohort have higher levels of accuracy is not depending on recall and is ideal for examining risk factors over time due to the longitudinal followup 45 these datawith a large n and a number of covariatesare wellsuited for propensity scoring a significant limitation is that certain covariates and mediating effects are unobservable due to lack of information the data can only capture recorded variables for example only individuals seeking mental health treatment will receive a diagnosis which may not be include all individuals with mental health conditions 46 sensitivity testing addresses this limitation but such covariates might well have impacted study results as mentioned above not adjusting for involvement with child protective services is a limitation although the number of teenage girls involved with cfs is relatively small they may not be interacting with their mother or older sister on a regular basis and thus are less likely to model themselves after their family members the availability of an educational predictor was an identified limitation to account for the impact of educational achievement in our full cohort educational outcomes would need to be available for everyone for grade 7 at the latest since educational achievement generally remains quite similar from year to yeargrade 9 achievement is likely to be quite similar to grade 7 achievement 30 this reduced odds ratio may better estimate the true odds in several years such variables can be incorporated into models of teenage pregnancy additionally we were unable to identify aboriginal individuals this is a limitation as teenage pregnancy rates are more than twice as high in the aboriginal population than in the general population 47 family and peer relationships social norms and cultural differences will likely never be measured through administrative data limiting the degree to which these confounders can be controlled for conclusions this paper contributes to understanding of the broader topic who is influential about what within the family the teenage pregnancy risk seen in younger sisters when older sisters had a teenage pregnancy appears based on the interaction with that sister and her child the family environment experienced by the siblings is quite similar much of the pregnancy risk among teenage daughters of mothers bearing a child before age 20 seems likely to result from the adverse environment often associated with early childbearing given that an older sisters teenage pregnancy has a greater impact than a mothers teenage childbearing social modelling may be a stronger risk factor for teenage pregnancy than living in an adverse environment appendix 1 pregnancy diagnosis codes appendix 2 adjustment for educational achievement to account for the impact of educational achievement on teenage childbearing the grade 9 achievement index was adjusted for in a subpopulation of individuals who had not had a pregnancy prior to age 16 as educational achievement was measured using the grade 9 achievement index which is based on average marks in all classes and the number of credits earned during the school year 31 individuals had to have at least finished grade 9 before becoming pregnant to use this variable as a predictor older sisters teenage pregnancy status after propensity score matching the final sample consisted of 1721 cases and 3442 controls tstatistics were calculated for each covariate before and after matching to check for covariate balance any point outside of the two vertical dotted lines signified a statistically significant covariate all covariates differed significantly in the unmatched sample after matching the tstatistics of all covariates fell within the nonsignificant region indicating balance in cases and controls mothers teenage childbearing status after propensity score matching the final sample consisted of 1499 cases and 2998 controls tstatistics were calculated for each covariate before and after matching to check for covariate balance any point outside of the two vertical dotted lines signified a statistically significant covariate all covariates differed significantly in the unmatched sample after matching the tstatistics of all covariates fell within the nonsignificant region indicating balance in cases and controls authors contributions ew participated in the design of the study carried out the analysis and drafted the manuscript lr conceived of the study and participated in its design and coordination and helped to draft the manuscript nn participated in its design and interpretation of results all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background risk factors for teenage pregnancy are linked to many factors including a family history of teenage pregnancy this research examines whether a mothers teenage childbearing or an older sisters teenage pregnancy more strongly predicts teenage pregnancy methods this study used linkable administrative databases housed at the manitoba centre for health policy mchp the original cohort consisted of 17115 women born in manitoba between april 1 1979 and march 31 1994 who stayed in the province until at least their 20 th birthday had at least one older sister and had no missing values on key variables propensity score matching 12 was used to create balanced cohorts for two conditional logistic regression models one examining the impact of an older sisters teenage pregnancy and the other analyzing the effect of the mothers teenage childbearing results the adjusted odds of becoming pregnant between ages 14 and 19 for teens with at least one older sister having a teenage pregnancy were 338 99 ci 277413 times higher than for women whose older sister s did not have a teenage pregnancy teenage daughters of mothers who had their first child before age 20 had 157 99 ci 130189 times higher odds of pregnancy than those whose mothers had their first child after age 19 educational achievement was adjusted for in a subpopulation examining the odds of pregnancy between ages 16 and 19 after this adjustment the odds of teenage pregnancy for teens with at least one older sister who had a teenage pregnancy were reduced to 248 99 ci 201306 and the odds of pregnancy for teen daughters of teenage mothers were reduced to 139 99 ci 115168 conclusion although both were significant the relationship between an older sisters teenage pregnancy and a younger sisters teenage pregnancy is much stronger than that between a mothers teenage childbearing and a younger daughters teenage pregnancy this study contributes to understanding of the broader topic who is influential about what within the family

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introduction secondhand smoke can have severe health consequences for nonsmokers such as cancer asthma chronic obstructive pulmonary disease and various heart diseases 1 therefore implementation of smoking restrictions to protect people from exposure to tobacco smoke was incorporated into article 8 of the framework convention of tobacco control by the world health organization 2 smoking restrictions have been implemented by many countries that ratified the fctc although a recent study indicated that the adoption rate of smoking restrictions was highest immediately after the ratification of the fctc and that this effect of the fctc decayed within several years 3 previous research showed that compliance with smoking restrictions is relatively high in most developed countries 4 5 6 7 smoking restrictions that are complied with are effective in reducing secondhand tobacco smoke exposure 689 however little is known about the social acceptance of smoking restrictions it is possible that smokers comply with the restrictions simply because they have to but that they would resume smoking if it was allowed again high acceptance of smoking in public places would indicate that people are not aware or do not agree with the need and benefits of smoking restrictions which increases the risk of noncompliance smokers could defy smoking restrictions or could pressure owners of public venues to allow them to smoke for example in the netherlands smoking is tolerated late at night in some bars when bar owners think that chances of compliance checks are low 10 furthermore some concerns have been voiced suggesting an increase in smoking at home after implementation of smoking restrictions in public places these concerns include that if smokers would comply with those smoking restrictions they would compensate the lack of smoking opportunities in the public sphere by more smoking in the private sphere according to the last refuge model especially restrictions at recreational venues would lead to more smoking at home and therefore more exposure to secondhand smoke to other family members 11 whereas smokers may have to show public commitment to smoking bans they still could lack private commitment leading to no personal acceptance of smoking restrictions the installment of smoking bans at home is a reflection of such personal acceptance of nonsmoking we therefore examined both acceptance of smoking in public places and implementation of home smoking bans in the current study an increase in unacceptance of smoking in public places as well as at home would be an indicator that smoking restrictions might lead to denormalization of smoking instead of merely obeying the law other studies showed that smoking restrictions can indeed increase smokers feelings of being stigmatized and change social norms about smoking 1213 previous studies showed decreases over time in acceptance of smoking in public places and increases in support of smoking bans 9 14 15 16 moreover previous research indicates that implementation of smoking restrictions in public places probably does not result in an increase of smoking at home but may even lead to a decrease 7 17 18 19 however most previous studies focused on smoking restrictions at one venue and did not examine longterm trends acceptance of smoking in public places and implementing home smoking bans may differ within certain groups previous studies found mixed results regarding sociodemographic differences but did find that nonsmokers were more supportive of smoking restrictions and more likely to implement home smoking bans than smokers 15161819 further information about whether subgroup differences can be found could be important to develop targeted interventions in order to increase social acceptance of smoking restrictions for example by educational campaigns smoking restrictions in the netherlands smokefree workplaces including public transportation were implemented in january 2004 in the netherlands and this legislation has not changed since implementation of a smokefree hospitality sector however did not proceed that straightforward 20 21 22 23 in july 2008 a smoking ban for the hospitality sector was implemented comparable to other workplaces owners of hospitality venues were allowed to create designated smoking rooms but personnel was not allowed to serve there several owners of small bars were unwilling to comply with this legislation and joined the organization save the small hospitality industry entrepreneur that was set up to fight the smoking ban and that had ties with the tobacco industry 20 after lawsuits by bar owners against the state the smoking restrictions were reversed in july 2009 for owneronly bars with no further employees and smoking was allowed there again in february 2010 the supreme court overruled this decision and determined that smoking restrictions should apply to all hospitality venues as originally intended in june 2010 a general election took place in the netherlands which resulted in the formation of a new government the decision of the former government to apply smoking restrictions to all hospitality venues was reversed again for small bars without employees in november 2010 by the newly elected government 22 in february 2013 a voting about hospitality industry smoking restrictions took place within the government that resulted in the decision to apply the smoking ban to all hospitality venues again which was realized in october 2014 however owners of hospitality venues were still allowed to have designated rooms where smoking was allowed the netherlands food and consumer product safety authority investigated compliance with smoking restrictions at various hospitality venues this research was done by observations of the venues and reporting the number of venues where no smokers were seen 2425 figure 1 gives an overview of the various policy changes and compliance with smoking restrictions in bars and clubs in the netherlands from 2005 to 2014 it shows that compliance decreased when smoking restrictions were partially reversed but later increased again the aim of the current study was to investigate trends in social acceptance of smoking restrictions during 10 years of implementation reversal and reenactment of smoking restrictions in the netherlands in addition we examined which sociodemographic factors were associated with social acceptance of smoking restrictions and whether these associations changed over time methods design and sample we used data from the dutch continuous survey of smoking habits the dcssh is a national population survey with a crosssectional design in which respondents aged 15 years and older are surveyed weekly respondents of the dcssh are randomly selected from a nationally representative panel of marketing research agency tns nipo this panel includes more than 140 000 potential respondents who regularly participate in internetbased research and who are actively recruited by tns nipo via mail and telephone for the current study we used data from 2005 to 2014 between 2005 and 2008 surveys were conducted using household web interviewing as of 2009 personallevel web interviewing was used approximately 18 000 respondents participated in the survey each year measurements acceptance of smoking in public places to assess acceptance of smoking in public places we asked six questions on a 5point scale about whether respondents found it acceptable to smoke in places where smoking was not allowed that is in a restaurant in a bar in public transportation and at schools as well as in places where smoking is still allowed that is in the car with nonsmokers and on the street as of 2008 also data from two additional venues were available acceptance of smoking at workplaces and smoking on terraces of restaurants and bars to investigate trends of acceptance we used mean values of these variables from each included survey year to examine associations of acceptance with other factors we combined all items except smoking at workplaces and smoking on terraces into one scale home smoking bans to measure the rules about smoking at respondents homes we asked respondents who were living with at least one young child in their home do people smoke at your home 1 always 2 regularly 3 sometimes 4 never the first three answers were combined indicating having implemented no home smoking ban while the last option indicated having a complete smoking ban inside a respondents house covariates covariates were sex age gross yearly household income level of completed education and smoking status age was categorized into 1524 years 2539 years 4054 years and 55 years and older income was categorized into three groups low moderate and high level of education was also categorized into three groups low moderate and high university education and higher professional education to determine the smoking status all respondents were asked do you smoke or do you not smoke at all respondents who answered that they smoked were defined as current smokers respondents who answered that they did not smoke were asked have you smoked in the past respondents who answered that they had smoked in the past were defined as exsmokers and respondents who answered that they had not smoked in the past as never smokers 2627 analyses first we plotted trends of acceptance of smoking at all included venues and of having implemented a complete home smoking ban next we tested whether these trends changed significantly between the first and the last year of measurement using independentsamples t tests and pearson chisquare tests stratified by smoking status we furthermore conducted hierarchical linear and logistic regression analyses with three steps using the enter method the dependent variable was the scale for acceptance of smoking in the linear regression analysis and whether or not respondents had implemented a complete home smoking ban in the logistic regression analysis in the first step we tested whether acceptance of smoking and having a home smoking ban changed significantly between 2005 and 2014 by specifying survey year as continuous variable in the second step we added the above outlined covariates to identify factors associated with acceptance of smoking and having a home smoking ban in the third step we included interaction terms on top of the main effects for all covariates by survey year to examine whether associations changed over time we performed sensitivity analyses with each interaction included separately into the third model of both regression analyses and the pattern of results remained the same compared to the models with all interactions included to get more specific information about trends at the different venues we performed secondary analyses with acceptance of smoking for each venue as separate outcome measures respondents had the opportunity to refuse answering the income question or to answer with dont know these responses were recoded as missing values and excluded from the analyses resulting in a sample size of 142 083 respondents for the regression analyses in all analyses sampling weights for age sex educational level working hours geographic region urbanization figure 1 overview of the implementation and compliance with smokefree hospitality industry legislation in the netherlands and household size were applied to make the data representative for the dutch population we used an alpha level for significant differences of less than 005 all analyses were conducted with spss version 21 results sample description table 1 shows the sociodemographic characteristics and the smoking status of the included respondents due to the different method of data collection as of 2009 the distribution of scores before and after 2009 changed for age income and education the proportion of participants who were categorized as smokers decreased between 2005 and 2014 while the proportion of exsmokers slightly increased as did the proportion of never smokers trends in acceptance of smoking in public places and home smoking bans figure 2a shows the trends of acceptance of smoking at all included venues acceptance of smoking in public transportation in the car with nonsmokers and at schools was quite low ranging from 14 to 16 between 2005 and 2014 acceptance of smoking in public transportation at schools in restaurants and in bars decreased significantly between 2005 and 2014 among smokers exsmokers and never smokers the largest decrease was observed regarding smoking in restaurants among all three groups acceptance of smoking in cars with nonsmokers increased slightly but statistically significantly among all three groups and acceptance of smoking on the street increased significantly among smokers and never smokers acceptance of smoking at workplaces decreased significantly between 2008 and 2014 among all three groups as did acceptance of smoking on terraces we additionally analyzed the trends of unacceptance and of acceptance acceptance of smoking increased for all venues but only slightly unacceptance of smoking decreased for smoking on the street on terraces and in cars with nonsmokers remained stable for smoking in public transportation and increased for smoking in bars at work in restaurants and at schools the largest decrease in unacceptance was found for smoking on the street and the largest increase for smoking in restaurants figure 2b displays the trends of having implemented a complete home smoking ban separately for smokers exsmokers and never smokers smokers were least likely to have implemented a home smoking ban compared to exsmokers and never smokers having a complete home smoking ban increased significantly between 2005 and 2014 among all three groups in 2005 425 of the smokers 655 of the exsmokers and 779 of the never smokers had a smoking ban at home in 2014 this had increased to 551 of smokers 852 of exsmokers and 908 of never smokers factors associated with acceptance of smoking in public places and home smoking bans table 2 shows which factors were associated with acceptance of smoking at all venues combined acceptance of smoking decreased significantly between 2005 and 2014 indicating that respondents found smoking at all included venues less acceptable over time furthermore more acceptance of smoking was associated with being male being young having low income and education and being smoker all interaction terms that were added into step 3 were statistically significant the largest effect sizes were found for trend age and for trend smoking status results of stratified analyses revealed that the decrease of acceptance over time among respondents who were categorized into the younger age groups was larger compared to respondents from the older age groups furthermore acceptance of smoking decreased more over time among smokers than among exsmokers and never smokers in secondary analyses we examined the acceptance of smoking for each venue separately the same factors were associated with acceptance of smoking in these secondary analyses as in the analyses with all venues combined into one scale we also analyzed the interactions between trend age and trend smoking status for each venue separately these analyses revealed that the decrease over time regarding acceptance of smoking at schools in public transportation in bars in restaurants and at work was larger among respondents with a young than a high age but the decrease was larger regarding smoking on terraces among respondents with a high than a young age the increase regarding smoking in the car with nonsmokers and smoking on the street was largest among middleaged respondents furthermore the decrease over time regarding acceptance of smoking at schools in bars in restaurants and at work was largest among smokers while the decrease regarding smoking in public transportation and on terraces was largest among exsmokers the increase regarding smoking in the car with nonsmokers was largest among smokers and regarding smoking on the street among exsmokers table 2 also shows the factors associated with having implemented a complete home smoking ban first of all the odds of having a home smoking ban increased over time furthermore women were less likely to report having implemented a home smoking ban than men respondents aged 2539 years were more likely to report a home smoking ban than respondents aged 55 years and older respondents with low income and education were less likely to have implemented a complete home smoking ban than respondents with high income and education smokers were finally less likely to have a home smoking ban than never smokers none of the interaction terms for trend by covariate was statistically significant indicating that the factors associated with having implemented home smoking bans did not change significantly over time discussion the aim of the current study was to investigate changes in social acceptance of smoking restrictions during a decade of inconsistent smoking restrictions in the netherlands we used acceptance of smoking in public places and having implemented home smoking bans as indicators of social acceptance of smoking restrictions smoking in public transportation at schools in restaurants in bars and at workplaces became less acceptable over time at all these venues smoking was not allowed by law in 2014 in the netherlands it is notable that the largest decrease was found at venues where smoking restrictions were implemented during or immediately before the study period at workplaces and at the hospitality sector yet the acceptance of smoking in bars remained quite high compared to smoking in restaurants the gap between these two venues only became wider from 2005 to 2014 it is likely that the frequent changes in legislation and the exemptions for small bars affected the acceptance of smoking previous research from the netherlands as well as other european countries showed that compliance with smoking restrictions was also lower at venues with partial compared to comprehensive policies 25 28 29 30 31 a smoother implementation of smoking restrictions in the netherlands might have led to lower acceptance of smoking in bars and higher compliance with the smoking ban in bars at levels comparable to restaurants we furthermore found a decrease regarding acceptance of smoking on terraces of hospitality venues and an increase regarding smoking on the street and regarding smoking in the car with nonsmokers at all three venues smoking was allowed by law in 2014 in the netherlands acceptance of smoking in cars with nonsmokers was already quite low in 2005 and remained low up to 2014 these findings indicate that high support from the population could be expected if smoking restrictions in cars with nonsmokers would be implemented for the time being implementation of a smoking ban on terraces of hospitality venues will probably not get a lot of support by the dutch population regarding home smoking bans we found that the dutch population increasingly implemented complete bans the concerns that the implementation of smoking restrictions in public places would be related to a displacement to smoking at home were not supported in the current study exsmokers as well as never smokers implemented consistently more home smoking bans than smokers between 2005 and 2014 the implementation of home smoking bans by smokers did decrease at first between 2007 and 2008 when the smokefree hospitality sector was implemented in the netherlands however as of 2008 the percentage of smokers who implemented home smoking bans increased again to levels much higher than 2007 the general increase could be an indicator of increasing personal acceptance and commitment to smoking bans we furthermore found that men people aged 2539 years people with a high socioeconomic background and never smokers were most likely to have implemented a complete home smoking ban these findings are in line with several previous studies 193233 future research should investigate how acceptance of smoking in public places and the implementation of home smoking bans interact or are causally related to each other we found in our study that public smoking restrictions did not lead to compensation by more smoking at home but rather added to denormalization of smoking by a decrease in smoking at home therefore it is possible that tightening of public smoking bans leads to more home smoking bans we found a number of subgroup differences regarding acceptance of smoking in public places and implementing home smoking bans a low level of social acceptance of smoking restrictions was in particular observed among people with a low socioeconomic background and smokers measures to increase this acceptance for example campaigns to increase knowledge and awareness of the harm of secondhand smoke should therefore be targeted at these groups a notable finding of the current study was that the decrease of acceptance of smoking in public places over time was largest for younger respondents and smokers this is reassuring because the longterm limitations and strengths one limitation of the current study is the change in survey methodology as of 2009 that led to changes in the sample composition therefore it might be possible that our results are not fully generalizable to the entire dutch population another limitation is that we could only include data from the netherlands it would be interesting to compare the findings of the current study with data from other countries to get information about whether the dutch trends can also be observed elsewhere for example in countries that implemented comprehensive smoking restrictions all at once moreover our design was crosssectional and therefore not suitable to draw conclusions about causality future research could measure social acceptance of smoking restrictions longitudinally to track individual changes over time strengths of the current study are the large sample size and that we could analyze data from quite a long period of time with many changes in the smoking restrictions which gives valuable insight into longterm developments and trends conclusion social acceptance of smoking restrictions increased among the dutch population between 2005 and 2014 despite a suboptimal implementation process of smoking restrictions in bars however acceptance of smoking remains quite high for some public places especially for bars higher successes could probably have been obtained with a smoother policy implementation process the dutch population increasingly implemented home smoking bans indicating that the implementation of smoking restrictions in public places was not related to a displacement to smoking at home supplementary material supplementary table s1 can be found online at oxfordjournalsorg declaration of interests none declared

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however the complexity of the issues we face as social workers forces us to consider whether it is desirable much less even possible to identify cause and effect and if so what is the best means for doing so the issue of desirability has been raised in conjunction with criticism of the value of the scientific method in general and scientifically based evidencebased practice in particular the issue of feasibility has been raised in conjunction with the claim that the complexity of social phenomena renders the use of scientific methods as problematic and incomplete these questions are by no means limited to social work but they are central to our consideration of whether it is possible to develop a science of social work and if so how we go about doing it this article has four aims provide an overview of the nature of causality and causal inference examine how causality and causal inference are treated in social work research and practice highlight the role of quantitative and qualitative methods in the search for causality and demonstrate how both methods can be employed to support a science of social work the nature of causality and causal inference the human sciences including social work place great emphasis on understanding the causes and effects of human behavior yet there is a lack of consensus as to how cause and effect can and should be linked what little consensus exists seems to be that effects are assumed to be consequences of causes causes and effects may be singular in nature or they may be multifactoral this relationship can be viewed both spatially and temporally for instance the presence of a depressive disorder in an individual may have some determinants that are distal and some determinants that are proximal to the current episode of depressive symptoms a link between one or more causes and one or more effects may also be viewed as direct and indirect thus while the death of a spouse may contribute to the onset of a depressive disorder it may do so directly or indirectly by virtue that it deprives the survivor of an important source of social support likewise the death of a spouse may contribute differentially to the risk of a depressive disorder depending on whether the survivor is a male or female causal inference in turn may be viewed as the process of establishing the link between the perceived cause or causes and the perceived effect or effects causation may also be viewed from the perspective of the distinction between necessary and sufficient causes for instance a given exposure is considered a necessary cause of an outcome if the outcome does not occur in its absence it is a sufficient cause if it always leads to an outcome without requiring the presence or absence of any other factors however causes may also be multifactorial in which case causes are neither necessary nor sufficient for any given individual the necessary and sufficient cause definitions assume that all causes are deterministic while a probabilistic view of causation is one in which a cause increases the probability or chance that its effect will occur but may be neither necessary nor sufficient for its occurrence kramer and others argue that a probabilistic definition of causation is more consistent with the aims of applied human sciences like public health our current notions of causation and causal inference generally owe their intellectual origins to the british social philosopher david hume humes criteria of causation emphasize the importance of a temporal priority in which causes must necessarily occur or exist prior to the occurrence or existence of an effect humes criteria also stresses the onetoone relationship between cause and effect like hume these criteria give priority to the temporal relationship between a cause and effect and to specificity but also suggest the importance of measurement or quantification of the relationship and experimental designs lewis argues that causal inference is an essential part of social work practice as well as social work research however the association between causality and causal inference in the field of social work and logical positivism and critical rationalism with its emphasis on universal laws has subjected the search for causal linkages to criticism from those who view it as deterministic limited in its ability to address the complexity of social phenomena and inconsistent with the goals of the profession as padgett observes antipositivistic skeptics question whether the search for causation is plausible or desirable given the postmodern premise that facts are fictitious nevertheless embedded in much of social work research is an implicit understanding that actions have consequences and that most of the characteristics of the human condition can be linked directly or indirectly to one or more factors or events that are in some way responsible for that condition causality in social work research and practice in social work research randomized controlled trials have been used primarily to demonstrate causal linkages between specific interventions that are treated as independent variables and specific outcomes that are treated as dependent variables for instance ell and colleagues assessed the effectiveness of an evidencebased socioculturally adapted collaborative depression care intervention for treatment of depression and diabetes in a group of 387 predominately hispanic primary care patients recruited from two safety net clinics the causal chain tested in this study was that the intervention resulted in an improvement in mood which in turn resulted in improvement in hemoglobin a1c levels in this instance improvement in h1c levels was a direct effect of the reduction in depressive symptoms and an indirect effect of the depression treatment intervention in another example glisson and colleagues conducted a rct of the effectiveness of multisystemic therapy and the availability responsiveness and continuity organizational intervention in reducing problem behavior in delinquent youth residing in 14 rural counties in tennessee using a 2 × 2 design in which youth were randomized into receiving mst or treatment as usual and counties were randomized into receiving the arc intervention a multilevel mixed effects regression analysis of 6month treatment outcomes found that total youth problem behavior in the mst plus arc condition was at a nonclinical level and significantly lower than in other conditions the causal chain tested in this study was that the arc intervention resulted in the successful implementation of mst which in turn resulted in a reduction of youth problem behavior in this instance reduction of youth problem behaviors was a direct effect of the mst intervention and an indirect effect of the arc organizational intervention however qualitative methods have also been used in social work research to make causal inferences linking two sets of phenomena for instance gutierrez glenmaye and delois conducted interviews with administrators and staff at six different agencies to identify elements of the organizational context of empowerment practice using a modified grounded theory approach they identified four sets of factors that constitute barriers to maintaining and implementing an empowermentbased approach in social work practice for instance differing philosophies or politics of more traditional service providers negatively affected the willingness or ability of empowermentbased agencies to refer clients to other services gutierrez glenmaye delois 1995 p 252 parentheses added alaggia and millington conducted a phenomenological analysis of the lived experience of 14 men who were sexually abused in childhood to generate knowledge … on the effects of boyhood sexual abuse on the present lives of men and to understand how those effects found expression in mens everyday lives in this instance sexual abuse during childhood is treated as the cause and anger and rage sexual disturbance and ambivalence and loss and hope were identified as effects the attempt to examine effects of childhood sexual abuse using a phenomenological approach is especially noteworthy because the focus on interpretative understanding or verstehen is often seen as a rejection of causal understanding qualitative and quantitative perspectives on causality although these two studies are representative of the use of different qualitative methodological approaches to identify connections between certain phenomena and certain outcome in social work as in other fields priority in the determination of causality is given to quantitative methods in general and rcts in particular otto and ziegler note that rcts are considered the best form of evidence of practice effectiveness and therefore of causality these designs serve to control or cancel out and differences that are effects of other events to assess whether event x as independent variableis nonspuriously conjunct with event y in the context of a controlled ceteris paribus condition they further argue that the criteria of using the rct design to determine causal connections between an intervention and its outcomes can hardly be applied to qualitative research such as ethnographic studies or deep hermeneutical interviews consequently qualitative studies are placed on a lower rank of evidence of causality and below what cook and campbell considered as the minimum interpretable design necessary and adequate for drawing valid conclusions about the effectiveness of treatments however there are inherent limitations to relying on rcts to determine causality in social work research circumstances may preclude the use of the rct design including small sample sizes especially in multilevel studies where single individuals are embedded in organizations like schools or agencies concerns about external validity the ethics of providing service to one group and denying the same service to another group of clients the expense and logistics involved in conducting such research the unwillingness of participants or organizations to accept randomization and the expense and logistical challenges in conducting longitudinal followup assessments furthermore causal models can be constructed using quantitative or qualitative data in the example presented in figure 1 the model of social capital effects on psychosocial adjustment of chinese migrant children was developed by wu palinkas and he using structural equation modeling on the other hand using qualitative data collected from leaders of countylevel child welfare mental health and juvenile justice systems in california palinkas and colleagues also developed a model of interorganizational collaboration that posited causal linkages between characteristics of the outer context inner context and characteristics of the collaboration itself and the structure of social networks that in turn are linked to the pace and progress of implementation of evidencebased practices finally not all qualitative methodologists have rejected the notion that the construction of causal inferences is both desirable and possible miles and huberman for instance aim to account for events rather than simply to document their sequence we look for an individual or a social process a mechanism a structure at the core of events that can be captured to provide a causal description of the forces at work sayer argues that causal explanation is not only legitimate in qualitative research but a particular strength of this approach although it uses a different strategy from quantitative research based on a process rather than a variance concept of causality ragins qualitative comparative analysis involves representing each case as a combination of causes and effects that can then be compared with each other another qualitative comparative method analytic induction is described as an exhaustive examination of cases in order to prove universal causal generalizations denzin considered analytic induction to be one of three major strategies for establishing the existence of a causal relationship the other two being the statistical method and the experimental method even lofland considered a skeptic of the search for causation argued that the strong suit of the qualitative researcher is the ability to provide order rich descriptive detail stating that it is perfectly appropriate that one be curious about causes so long as one recognizes that whatever account or explanation he develops is conjecture it would seem therefore that quantitative and qualitative methods each present certain advantages and disadvantages in making causal inferences whether one identifies with a logical positivist or postpositivist or a postmodernist social constructivist view of human nature or is more at ease with the process of counting quantitative data or interpreting qualitative data however as no single method is adequate to the challenge of linking cause and effect in a deterministic or probabilistic fashion it is perhaps prudent to heed the advice of campbell who maintained that because proving causality with certainty in explaining social phenomena is problematic and because all methods for proving causality are imperfect multiple methods both quantitative and qualitative are needed to generate and test theory improve understanding over time of how the world operates and support informed policy making and social program decision making causality and the science of social work the path to causality can be viewed as moving across a series of steps that begin with identification and proceed to description explanation generation explanation testing and prescription or control identification first occurs through reports or studies that point to the existence of a previously unknown or unrecognized phenomenon description of the phenomenon may involve qualitative andor quantitative data both methodological approaches may be employed in the next step which is the identification of associations between variables and the generation of hypotheses to be tested that can help to explain why the variables are in association with one another the next step is then to test the hypotheses and the validity of the presumed explanation this step usually requires the use of prospective longitudinal designs and the use of quantitative methods the final step is the construction of experimental conditions that enable the investigator to simultaneously control for the possibility of alternate explanations for the observed association between one variable presumed to be the cause and the other variable or variables presumed to be the effect this step usually requires the use of the rct design and the use of quantitative methods one can conceive of two separate arguments that link these discrete steps in a meaningful way in the first argument the further we proceed along the path of scientific inquiry the more we rely on quantitative methods to make causal inferences and support the existence of a causal linkrelationship however as noted previously there are inherent limitations to relying on rcts to determine causality in social work research in the second argument qualitative and quantitative methods each make distinct contributions to the task of proving causality thus in using quantitative methods priority is placed on confirmation of hypothesis through experimentation and a narrow or segmented focus on potential causal explanations while in using qualitative methods priority is placed on exploration of phenomenon and generation of hypotheses through observation and a broad or holistic focus on the social context in which causal links occur although they may differ with respect to the value placed on each set of methods both arguments posit a relationship between qualitative and quantitative methods and both assume that each set of methods has a role to play in understanding causality and in making causal inferences relationships between the two sets of methods have been increasingly articulated using the terminology of mixed methods defined as the integrated use of quantitative and qualitative methods in ways that provide greater understanding or insight into a phenomenon that might be obtainable from either method used alone cresswell and plano clark identify five different types of mixed methods designs a triangulation design is used when there is a need to compare results from different sources of information regarding the hypothesized same phenomenon or parameter to seek corroboration an explanatory or complementary design is used to understand a phenomenon more comprehensively or completely an exploratory design is used for instrument taxonomy or typology development where qualitative data serve as an initial exploration to identify variables constructs taxonomies or instruments for a subsequent quantitative study phase an embedded or expansion design is used to assess hypothesized different phenomena or parameters using different methods finally an initiation or transformative design is used to understand a phenomenon more insightfully discovering new ideas perspectives and meanings each of these designs may be used to identify describe explain verify and control the relationships linking one phenomenon or set of phenomena to another phenomenon or set of phenomena in a causal fashion this combined use of quantitative and qualitative methods may occur simultaneously in which one method usually drives the project theoretically with the supplemental project designed to elicit information that the base method cannot achieve or for the results to inform in greater detail about one part of the dominant project or sequentially in which the method that theoretically drives the project is used first with the second method designed to resolve problemsissues uncovered by the first study or to provide a logical extension from the findings of the first study an illustration of the use of mixed method designs to examine causality and causal inference can be found in the child steps effectiveness trial carried out by the research network on youth mental health and funded by the john d and catherine t macarthur foundation the cset focused on children aged 813 who had been referred for treatment of problems involving disruptive conduct depression anxiety or any combination of these ten clinical service organizations in honolulu and boston 84 therapists and 174 youths participated in the project youth participants were treated with the usual treatment procedures in their settings or with one or more of three selected evidencebased treatments cognitivebehavioral therapy for anxiety cbt for depression and behavioral parent training for conduct problems these evidencebased treatments were tested in two forms standard manual treatment using full treatment manuals and modular treatment in which therapists learn all the component practices of the evidencebased treatments but individualize the use of the components for each child guided by a clinical algorithm and measurement feedback on practices and clinical progress a cluster randomization design was employed with therapists assigned to one of three conditions and youth who met study criteria randomized to treatment delivered by one of these three groups of therapists mixed effects regression analyses showed significantly superior outcome trajectories for modular treatment relative to usual care on weekly measures of a standardized brief problem checklist and a patientgenerated top problems assessment and youths receiving modular treatment had significantly fewer diagnoses than usual care youths at posttreatment in contrast none of these outcomes showed significant differences between standard treatment and usual care followup tests also showed significantly better outcomes for modular treatment than standard treatment on the weekly trajectory measures in general the modular approach outperformed usual care and the standard approach on the clinical outcome measures and the standard approach did not outperform usual care although the use of the modular approach to evidencebased treatment was assumed to have caused an improvement in behavioral health outcomes in this population the quantitative data alone could not explain why the modular approach was more successful than the standard approach to address that question a qualitative study of the process of ebt dissemination and implementation was embedded in the rct semistructured interviews and focus groups were conducted with included 38 therapists six project supervisors and eight clinical organization directors or senior administrators to identify patterns of use of the ebts once the randomized trial had been concluded twentysix of the 28 therapists who had been assigned to the standard or the modular conditions reported using the techniques with nonstudy cases subsequent to the conclusion of the trial however the pattern of use among all therapists including those in the standard manualized condition was more consistent with the modular approach while all of the therapists in these two conditions thought the ebts were helpful what distinguished the two groups of therapists was the perception that the modular approach allowed for more flexibility accommodation and control over the therapeutic alliance with clients than the standard approach both therapists and supervisors felt that the modular approach gave them more license to negotiate with researchers with respect to circumstances in which the modules could themselves be modified or more often than not supplemented with additional materials and techniques acquired through experience with working with similar clients conclusion we began by asking three questions the first was whether it is desirable for social workers to identify cause and effect it is desirable if we believe social work to be an applied empirically grounded social and cultural science aiming at both causal explanation and interpretative understanding one that includes elements of logical positivism and postmodernist social constructivism it is also desirable if the foundation of our profession is to change the lives of our clients for the better as kramer makes a similar argument for examining causality in public health stating that an understanding of cause is essential for change … a deliberate intervention will be successful in altering outcome only to the extent that the exposure is a true cause of that outcome alternatively we might question whether it is possible to develop and implement a solution without a comprehensive understanding of the problem one is trying to solve to answer that question we would have to determine whether that understanding can be comprehensive without understanding the cause of a problem further even if the solution mitigated the consequences of the problem is it truly an effective solution if the cause remains unaddressed the second question we addressed was whether it is possible for social workers to determine causality social workers face inherent challenges in adopting exclusively positivist criteria for determining causality making connections between a cause and an effect is possible whether one adheres to a positivist or a social constructivist view of society and behavior if understanding cause and effect is the foundation of any science then that understanding is possible if it is seen as a process and not as a specific outcome especially if the process and outcome are both contextspecific finally we asked about the best means of determining causality or making causal inferences if it is both possible and desirable for social workers to do so the answer is that both qualitative and quantitative methods can and should be used to fulfill specific roles in that process qualitative methods would be especially important in the early exploratory stages of scientific inquiry and for providing indepth understanding of the causal chain and the context in which it exists quantitative methods would be especially important in the later confirmatory stages of scientific inquiry and for generalizing findings to other populations in other settings both methods are fundamental to a science of social work the integrated use of quantitative and qualitative methods is certainly not a novel concept haight for instance called for the integration of postpositivist perspectives of critical realism with an emphasis on quantitative methods and research designs and interpretative perspectives with an emphasis on qualitative or mixed research designs and methods while postpositivist research using quantitative methods can help to identify generally effective interventions and eliminate the use of harmful or ineffective interventions … interpretist research using qualitative methods can enhance understanding of the ways in which cultural context interact with interventions resulting in diverse outcomes epsteins model of evidenceinformed practice calls for the integrated use of evidencebased practice with its emphasis on standardized quantitative measures and rct designs and reflective practice with its emphasis on qualitative observation what is novel here is that the process of making causal inferences is not limited to quantitative methods or rct designs perhaps the greatest challenge we face in creating a science of social work is being faithful to the principles of scientific inquiry on one hand while simultaneously being responsive to the needs activities traditions and multiple perspectives of our discipline the diversity of these needs activities traditions and perspectives reflect the complexity of the problems we seek to solve and the underlying factors that are responsible for those problems this complexity makes it difficult to identify single or specific causes of single or specific effects however while this complexity may be viewed as an obstacle to the creation of a science of social work it also represents a unique opportunity to create a science that acknowledges the importance of qualitative as well as quantitative methods of practicebased evidence as well as evidencebased practice and explanation grounded in social constructivism as well as logical positivism title description temporal relationship exposure must always precede the outcome strength the stronger the association the more likely that the relation of x to y is causal doseresponse relationship an increasing amount of exposure increases the risk consistency the association is consistent when results are replicated in studies in different settings using different methods plausibility the association has some theoretical basis or agrees with currently accepted understanding of pathological processes consideration of alternative explanations have other possible explanations been considered and ruled out experiment the condition can be altered by an appropriate experimental regimen specificity a single putative cause produces a specific effect coherence the association should be compatible with existing theory and knowledge source hill res soc work pract author manuscript available in pmc 2015 march 26

achieving the goals of social work requires matching a specific solution to a specific problem understanding why the problem exists and why the solution should work requires a consideration of cause and effect however it is unclear whether it is desirable for social workers to identify cause and effect whether it is possible for social workers to identify cause and effect and if so what is the best means for doing so these questions are central to determining the possibility of developing a science of social work and how we go about doing it this article has four aims 1 provide an overview of the nature of causality 2 examine how causality is treated in social work research and practice 3 highlight the role of quantitative and qualitative methods in the search for causality and 4 demonstrate how both methods can be employed to support a science of social workmixed methods outcome study methodological article field of practice in defining the mission of the profession of social work to enhance human wellbeing and help meet the basic needs of all people the preamble of the national association of social workers code of ethics 2013 places great emphasis on the environmental forces that create contribute to and address problems in living implied in this emphasis is the assumption of a causal link between these environmental forces and the problems they create or contribute to for instance when faced with the challenge of providing care to a client with a depressive disorder we first attempt to identify the factors that contributed to the onset of the disorder furthermore to address these problems we must appropriately and effectively match a specific solution to a specific problem this too requires us to consider a causal link between the solution and its outcome elimination of the problem or mitigation and treatment of its impacts thus a client with a depressive disorder may benefit from treatment that addresses the symptoms which may involve pharmacotherapy andor psychotherapy

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introduction the entire world has been affected by the coronavirus disease pandemic caused by severe acute respiratory syndrome coronavirus 2 which has led to thousands of deaths each day the covid19 pandemic is one of the greatest public health calamities since world war ii and despite best efforts has been challenging to control recognizing the rapid spread of covid19 and the threats it poses the world health organization declared it an international public health emergency on 30 january 2020 this allowed countries to exert maximum effort and allot resources to limit the rapid transmission of sarscov2 despite the low fatality rate and government efforts people are living in uncertainty and fear as there is no vaccine for covid19 covid19 has weakened healthcare systems and economies emptied open spaces and filled hospitals the pandemic has separated many people from their family friends and workstations and has severely disrupted modern life to mitigate this unprecedented pandemic physical and social distancing along with nationwide lockdowns and restrictions have been implemented for the past few months in several countries covid19 is creating a profound impact on all parts of the community including the physical and mental health of the public the growing pandemic is augmenting existing mental health problems including loneliness anxiety paranoia panic depression and hoarding with longterm psychosocial impacts social distancing stress and fear are the main factors behind these psychological problems leading to a global increase in suicides selfisolation and quarantine measures disproportionately affect people especially older adults migrants laborers refugees people with chronic diseases and marginalized and vulnerable populations the covid19 cataclysm has become the most serious problem worldwide and its consequences have left no one untouched the effects of a pandemic intensify due to its diverse nexus of intertwined biological and socioecological factors this diverse nexus was coined a syndemic by medical anthropologist merrill singer in the 1990s to describe the relationship between hivaids substance use and violence a syndemic is defined as a synergistic interaction between socioecological and biological factors resulting in adverse health outcomes the covid19 pandemic has escalated into a syndemic due to several driving factors such as overcrowding loneliness uncertainty poor nutrition and lack of access to health services consequently depression suicide domestic violence and psychiatric illnesses have significantly increased social determinants of health such as poverty social inequality social stigma and the environment where people live and work greatly affect the intensity of the syndemic additionally xenophobia ostracism and racism are reported in many places generally people living in countries with higher social and economic inequalities have more coexisting noncommunicable diseases and are therefore more vulnerable to the syndemic impact of covid19 we argue that for people living with ncds covid19 is considered a syndemica synergistic pandemic that interacts with various preexisting medical conditions and social ecological and political factors and exacerbates existing ncds studies have reported higher proportions of frailty malnutrition psychological problems and coinfections including antimicrobial resistance pathogens among plwncds in lowand middleincome countries ncds have been recognized as a key risk factor for covid19 patients however vulnerability to catching sarscov2 increases in the presence of other preexisting factors prevailing inequalities in the social determinants of health including poor social economic and environmental conditions have an impact on various aspects of life such as health wellness and financial status for example plwncds with comorbidities and higher social and economic deprivation are less likely to access health services during this pandemic this results in worse health outcomes such as poor quality of life mortality suicide and increased hospitalization due to poor selfmanagement during the covid19 pandemic plwncds from disadvantaged groups are less likely to receive healthcare compared to plwncds from socially advantaged groups the disadvantaged population have a high chance of falling sick dying and experiencing catastrophe furthermore socioeconomically deprived individuals who were dependent on daily wages have lost their jobs this has pushed them further into poverty and poor health a synergistic association between the severity of covid19 and ncds was reported in china which shows the negative effects of this syndemic this suggests the urgency of a paradigm shift from a singlecondition approach to a syndemic approach to tackle the current and future impacts of pandemics among plwncds in lmics the pandemic is unlikely to end soon and it is difficult to predict the arrival of the next pandemic but the syndemic will certainly continue in lmics in this paper we discuss covid19 among plwncds exposure to ncd risk factors and the disruption of essential public health services for ncds it considers literature on this topic following a search on google and pubmed to identify publications that considered populations with covid19 and ncds we conclude by reflecting on strategies and policies that deal with the covid19 syndemic among plwncds in lmics covid19 among plwncds the global covid19 pandemic has resulted in 16923006 cases in 213 countries and territories around the world and two international conveyances with 664191 fatalities as of july 29 2020 covid19 cases are decreasing in many countries but the opposite is true in lmics such as india and brazil many seriously ill covid19 patients had multiple comorbidities for instance 962 of those who died in hospitals in italy had comorbidities the case fatality rate increases with age especially in countries with a high percentage of older adults the comorbidities were mostly ncds such as hypertension diabetes cardiovascular disease and chronic lung disease especially chronic obstructive pulmonary disease the prevalence of comorbidities is higher among covid19 patients compared to the general population who are not infected with coronavirus for instance 86 of the covid19 patients in india and 72 of the covid19 patients in china had comorbidities the prevalence of comorbidities is expected to be similar in other lmics where the prevalence of ncds is high however there is a lack of literature on this topic from lmics the health condition is more severe and mortality is higher among older adults with ncds and people with bacterial infections caused by antibiotic resistant pathogens such as superinfections ncds cause around 72 of deaths worldwide and are the primary cause of death in southeast asia among those aged 30 to 70 years lmics have a large ncd burden in some lmics such as india there is an early onset of ncds thereby increasing the risk of covid19 among young individuals the addition of covid19 to preexisting ncds results in increased morbidity and mortality ncds can exhibit several characteristics with infectious manifestations including parameters like a proinflammatory state and compromised innate immune response this condition is further worsened because many plwncds have been deprived of treatment for their diseases since the onset of the covid19 pandemic covid19 and exposure to ncd risk factors preventive methods for this pandemic such as physicalsocial distancing lockdowns selfisolation and quarantine may increase exposure to ncd risk factors such as the increased use of tobacco products and alcohol as coping strategies increased reliance on unhealthy processed foods and barriers to physical activities which lead to weight gain these factors increase the incidence of ncds and related mortality moreover financial crises and the lack of social contact might enhance the burden of anxiety and depression among plwncds the economic slowdown predisposes people to malnourishment which further increases the risk of infectious diseases disruption of essential public health services and the way forward since the covid19 pandemic began prevention and treatment services around the globe have been severely impaired and the disruption is worse in lmics the results from a survey conducted by the who in 155 countries revealed that plwncds were not able to access services for their health conditions which made their lives even more difficult during this crisis more than 53 of the surveyed countries reported partially or completely impaired services for ncds and related complications particularly after the covid19 trajectory changed from sporadic to community transmission this is supported by the stories and pictures of plwncds captured in the news and social media of lmics where people were unable to access basic medicines or care for their chronic conditions this problem is exacerbated by the reassignment of health staff from ncd facilities to covid19 in all surveyed countries and the disruption of medical supplies and diagnostics as a result of nationwide lockdowns for example in india some outpatient services have been temporarily closed and hospitals have been converted into designated covid19 care homes this arrangement will have a further adverse effect on access to healthcare services and treatment adherence by plwncds similar painful stories regarding plwncds have been reported in the news and social media platforms of many lmics such as nepal bangladesh brazil pakistan ghana and iran governments in various countries have made efforts to focus on ncd services while tackling covid19 but only 42 of lowincome countries have done so compared to 72 of highincome countries this shows the global impact of covid19 on the disruption of healthcare services for ncds the interaction of covid19 with other biological and social factors appears to increase the risk of complications worsen health outcomes and intensify the burden on healthcare professionals and health systems on the one hand there is a global rush to respond to covid19 by increasing intensive care unit beds installing ventilators extending lockdowns and adopting other containment measures on the other hand there is a disruption of routine health services such as screening and diagnosis supplies of essential medicines and access to health service providers and support services the covid19 syndemic and other conditions have not only posed a challenge to health systems but have also exposed gaps within the healthcare delivery system in many hics and lmics due to covid19 the priorities of health services have shifted as a result the progress required to achieve sustainable development goals is threatened in the subsequent section we describe strategies that are essential to overcoming and managing the syndemic condition we divide these strategies into four broad categories essential supplies and information dissemination the sudden lockdowns imposed by authorities caused panic in many countries to avoid such situations there should be a supply of basic needs such as groceries and sanitary items home delivery is an important strategy that can be implemented with the help of volunteers especially for older adults and people with disabilities misinformation and fake news on social media platforms are fuelling this panic people should follow information from trusted sources such as government guidelines additionally authorities should disseminate the appropriate information to the general public in a timely manner selfmanagement support at the community level plwncds should be encouraged to monitor their symptoms practice selfcare adhere to medication seek healthcare services including counseling practice physical distancing wash their hands with soap and wear masks providing information on selfmanagement behavior changes for ncds and covid19 through sms and social media platforms is an important step in this situation health literacy and activation can play an important role in selfmanagement of conditions among plwncds in lmics promoting both the health literacy and empowerment of plwncds would enable patients to navigate health services use technology to contact healthcare providers develop problemsolving skills and adhere to healthy lifestyle behaviors healthy lifestyle activities must be promoted such as eating nutritious foods and engaging in physical and wellness activities individuals should have access to open spaces and be allowed to exercise at scheduled times while maintaining all precautionary measures and plwncds could be given timecards for physical activity the expansion of existing community health worker roles can be crucial to the selfmanagement of ncds and covid19 and to delivering basic services among plwncds during this extreme health workforce shortage particularly in lmics with weak health systems recovered covid19 patients can also spread information on health and selfcare management and help debunk the myths and lessen the stigma related to covid19 revitalizing healthcare delivery although countries are trying to provide care through telemedicine it is still in the formative stage while telemedicine is a boon for developed nations when it comes to the diagnosis treatment selfmanagement support and surveillance of conditions lmics with fragile health systems often struggle to launch telemedicine services using digital healthcare platforms in the health system would greatly increase access to the services and information required by plwncds this would in turn improve the management of chronic conditions and provide relief from emotional turmoil and stress in fragmented health systems chws can promote coordinated care by improving access to care and providing navigation support chws can also carry out surveillance of risk factors and implement preventive and selfmanagement strategies for plwncds who are at high risk of covid19 potential chw roles in covid19 management include community engagement community sensitization promoting isolation and quarantine and performing contact tracing despite their huge potential in pandemic management chws have been underutilized in the covid19 pandemic especially in countries where chws are available such as bangladesh india and nepal however before involving chws in the covid19 response they must be provided with appropriate training and adequate personal protective equipment while responding to covid19 the governments of lmics have failed to ensure health services for plwncds because of the blanket lockdown approach insufficient attention has been paid to the unnoticed drivers of covid19related mortality among plwncds while governments enforce mitigating measures during this pandemic they also need to develop strategies to map nationallevel data on ncd patients as such data do not exist in many lmics there is also a need to prepare care pathways for severely ill plwncds by engaging private and public healthcare institutions and delivering basic health services at the community level via mobile primary healthcare vans in many lmics outofpocket health expenditures are high and will rise further during the covid19 pandemic to reduce the burden of oop due to covid19 authorities should make provisions for free diagnostic and treatment facilities and focus on equitable accessible and affordable healthcare these measures will prevent the deterioration of health among plwncds amid the covid19 pandemic policy advocacy and research a situational analysis of available resources and resource planning must be carried out supportive packages should be provided to vulnerable groups such as older adults people with disabilities and the unemployed involving the private sector civil society academia nongovernmental and governmental organizations through intersectoral coordination and teamwork would address the situation with a syndemic lens hics can help lmics in setting up 247 helpline support to provide essential information and guidance related to the availability of services and contact in case of emergency authorities should also consider imposing different levels of restrictions by mapping the incidence and active cases of covid19 such as by designating red yellow and green zones providing an uninterrupted supply of funds is a major challenge for lmics during the covid19 pandemic international organizations philanthropists and industrialists through their corporate social responsibility should come forward to help countries facing a financial crisis highquality research and data on effective interventions to prevent the spread of infection and treatment of active cases are also needed moreover authorities should impose taxes on items such as sweetened beverages tobacco and alcohol to subsidize prices or lower taxes for nutritious food items and ease movement restrictions for food production processing and delivery which will indirectly lessen the use of unhealthy products conclusion covid19 and ncds have a reciprocal effect on each other ncds increase vulnerability to covid19 and covid19 increases ncdrelated risk factors the covid19 pandemic may not be the last to threaten the global community therefore there is a need to understand the drivers of the syndemic and design safety nets the health system must address not just one or some medical problems but ensure holistic care for those that need it particularly plwncds care for plwncds who are at most risk of covid19 must be included in national response frameworks and plans so that the government can protect citizens health and wellbeing during the current covid19 pandemic and for similar crises in the future otherwise the interaction of covid19 and ncds will result in disastrous effects that could be difficult to handle given the preexisting stress on healthcare delivery systems and impede progress in achieving the sustainable development goals the governments of lmics are crippled by a lack of technical and financial resources to address this overwhelming problem tackling the covid19 syndemic is a matter of urgency funding bodies that advocate for and want to be part of a change in lmics need to invest in prevention and health promotion programs that could address issues within a syndemic framework government agencies positioned to develop and implement policies must understand that asking citizens to sacrifice without providing appropriate support packages will not work rather than gearing up for a vertical approach governments concerned stakeholders development partners and civil society must build synergy across healthcare platforms to tackle this crisis through a holistic approach if they fail to do so the postpandemic era could experience a great divide in health equity that could be much worse than ever before undoing the progress made in developing healthcare policies and strengthening healthcare systems and infrastructure evidenceguided decisions must be made to overcome this formidable crisis in lmics data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2020 yadav rayamajhee mistry parsekar and mishra this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

the global coronavirus disease covid19 pandemic has greatly affected the lives of people living with noncommunicable diseases plwncds the health of plwncds worsens when synergistic epidemics or syndemics occur due to the interaction between socioecological and biological factors resulting in adverse outcomes these interactions can affect the physical emotional and social wellbeing of plwncds in this paper we discuss the effects of the covid19 syndemic on plwncds particularly how it has exposed them to ncd risk factors and disrupted essential public health services we conclude by reflecting on strategies and policies that deal with the covid19 syndemic among plwncds in lowand middleincome countries

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introduction the covid19 pandemic exposed the social and structural weaknesses differences of opportunities and bottlenecks of health systems around the world it highlighted the lack of commitment and preparedness of different sectors to build just and equitable societies brazil faces great challenges to combat covid19 these are aggravated by the social context which imposes a multiplicity of restrictions on living and health conditions especially for marginalized populations in peripheral and vulnerable regions of large cities additionally little is known about the transmission of the virus in the context of demographic and social inequality which characterizes a large part of the brazilian population who lives in crowded and precarious sanitation and housing conditions two concerns emerged from this unprecedented situation individual fear of having ones health affected and collective concern for the preservation of society researchers worldwide were mobilized to propose solutions to the crisis this led to an abundance of research news and recipes on how to survive this context scientists left their laboratories as they sought to fulfill their social role and share their knowledge and discoveries to lessen the impacts of the disease given the novelty complexity and lack of knowledge about the virus a controversial scenario also emerged it was characterized by mistrust and uncertainty regarding the role of science leading to doubts suspicions and disbelief about scientific findings and recommendations one example has been the controversies surrounding recommendations on the use of masks initially they were indicated only for health professionals and people with symptoms due to a shortage of personal protective equipment and to not generate a false sense of security in healthy people that could lead to a decrease in social isolation as scientists discovered the role of asymptomatic patients in spreading the infection and ppe inventories were regularized the recommendation to use masks began to expand general feelings of fear and uncertainty led to the creation of preservation strategies proposals emerged to alleviate the impacts of confinement on living conditions on affective relationships as well as on peoples attitudes toward collective spaces normative and prescriptive booklets videos and social media posts were created to protect civil society which was invited to adopt behaviors considered adequate and healthy in order to avoid contagion and to foster social isolation while such attempts are understandable it is important to pay attention to the excessive increase of advice from governments experts and amateur gurus on what needed to be done even though many of the recommendations were based on evidence the same scenario gave way to a myriad of information not always truthful aimed at containing the spread of covid19 overnight epidemiological concepts such as flatten the curve or reduce contagion peaks became part of everyday life initially health authorities issued recommendations that were not always effective given that informing people about the risks do not necessarily result in behavior changes a bombardment of information which may or may not be wellintentioned can create confusion more than be made available information needs to be interpreted understood and applied as such in order to be effective information must be adapted to the characteristics of their target audience that is they must incorporate an equity lens and consider existing vulnerabilities nevertheless responses aimed at tackling covid19 proposed by the government and the scientific community did not always consider the social inequalities that impact marginalized and vulnerable populations who were the most affected by social restrictions imposed by the disease in recent months discussions on the role of health promotion in combating the covid19 pandemic has increased under the argument that health promotion combined with the prevention of the new coronavirus could bring substantial contributions for health protection from the salutogenic perspective proposed by health promotion principles such as intersectoriality sustainability empowerment public participation equity and life cycle perspective are highlighted as options to guide responses to the health and social crisis we recognize the relevance of these contributions and highlight the brazilian national health promotion policy and its principles in order to comprehend the discourses produced and contribute with other perspectives to the current political scenario we assume the term perspective as a possibility and a belief in opportunities that are probable and good and most of all with hope toward the future the pnps principles express the fundamental practices of health promotion and support the idea of collective constructions that favor the protagonism of a multiplicity of actors stimulating cooperation and intraintersectoral integration fostering territorialized actions that recognizes local contexts and respects diversity encouraging democratic and transparent management in order to strengthen participation social control and coresponsibility governance for the development of sustainable actions and valuing solidarity and ethics health promotion faces great dilemmas to position itself in the current scenario we want to address one of them that we believe is appropriate to reinforce our argument that in this context one of the main roles of health promotion should be the ethical defense of life this dilemma refers to the practice of identifying the harmful effects of certain behaviors and practices and acting over individuals who are exposed to risks seeking to standardize their lifestyles very present in the context of the pandemic this way of thinking has been greatly disseminated in the name of health promotion discourses and practices aimed at delegating to subjects and social groups the task of taking care of themselves and exempting governments from the responsibility of guaranteeing the conditions for the population to tackle the situation have been reinforced we argue that there is a sophistication of strategies to assign blame to individuals and a focus on relating health protection to individual attitudes and personal organization that are disconnected from a collective perspective faced with an uncertain and unknown pandemic scenario within a context of vulnerabilities and political crises health promotion can be used to maintain the status quo as a strategy to standardize and control behaviors it can also contribute to strengthen alternatives such as the examples described below we aim to reflect upon what could be the role of health promotion in a situation such as the current brazilian one considering the possibilities that could point to innovative responses our discussion will highlight two factors that are interrelated and in the brazilian context strongly affect the scenario in which health promoting strategies are being implemented and the responses that are emerging to them the current political context characterized by a lack of governance and leadership and infodemics methodology a descriptive exploratory and qualitative study was conducted to analyze materials posted on the internet following the confirmation of the first covid19related death in brazil in march 2020 having health promotion as the analytical framework materials were selected from conventional brazilian internet media sources social networks and websites from the government world health organization and the pan american health organization the selection of materials followed these steps and criteria source and language materials in portuguese freely available on the internet identified through search engines such as google visit to websites publications on online mainstream media channels and those received through whatsapp groups related to health promotion content specificity materials contained the keywords covid coronavirus or covid19 and at least one of the following terms prevention health promotion care period of circulation materials posted between 15 march and 10 july 2020 inclusion criteria materials that offered good examples of the topics of interest to the article and analysis selected materials were readwatched by three researchers and the central ideas analyzed considering the health promotion framework results the review generated an enormous amount of materials as presented on table 1 particularly from media outlets and search engines which is characteristic of infodemic a thorough review was not feasible therefore a rapid review was conducted by surfing through titles and webpages the overwhelming majority of materials related to the term prevention which is understandable given the state of alarm installed with the beginning of the pandemic and a demand for information by society many materials were replicated across websites therefore eliminating duplicates was not possible the final analysis included a total of 76 documents discussion for this article we selected three of our analysis categories for discussion contextual aspects health promotion and control and health promotion in the defense of life political scenario and infodemic despite its historic structural challenges brazils public unified health system is considered an asset in the fight against the pandemic thanks to sus brazil has been able to successfully tackle past pandemics the countrys primary health care system and epidemiological surveillance which can play an important role in early detection of cases contact tracing and monitoring of risk groups has great population coverage nevertheless brazil is currently one of the epicenters of the covid19 pandemic brazilian president jair bolsonaro and his administration have refused to recognize the severity of the disease and the government response to the pandemic has been considered a public health disaster the federal governments reactions to the sanitary crisis have been marred by a lack of coordination technical capacity and leadership denialism promotion of unproven therapies attacks on who and the scientific community and dismantling of the countrys public health and research infrastructure since april two health ministers have left their post and currently the ministry of health is led by a military general who has replaced key technical posts within the ministry with other military personnel recently the government promoted a data blackout in an attempt to cover up covidrelated mortality rates the president himself has aggravated the situation by publicly minimizing the risks of the disease and disqualifying preventative measures promoted by the medical and scientific community he advocates for relaxing of social isolation measures and prioritizes restarting of the countrys economy over protecting lives recently mr bolsonaro has starred a series of controversial episodes such as outings through public places without wearing a mask in which he caused agglomerations and hugged supporters as widely reported on the brazilian media even after being diagnosed with covid19 on 7 july 2020 he continued to dismiss the severity of the disease removing his mask during the press conference in which he announced the test results potentially exposing reporters to the virus and later that day advocating for the use of hydroxychloroquine on live tv the governments lack of an effective unified national strategy to confront the pandemic coupled with the adversarial personality and callous actions of mr bolsonaro has contributed to a chaotic situation and created tremendous challenges for the implementation of coherent measures to control the disease for the foreseeable future another phenomenon has been recognized for negatively affecting global responses to the coronavirus outbreak and in brazil it has not been different infodemic who defines infodemic as an overabundance of information some accurate and some not occurring during an epidemic it makes it hard for people to find trustworthy sources and reliable guidance when they need it it is associated with a large increase of information associated with an specific topic that rapidly and exponentially multiplies generating a cycle of rumors and disinformation commonly known as fake news these in turn create speculation confusion and fears that can affect various aspects of peoples lives in relation to the pandemic who has identified four major thematic areas where people look for trustworthy information and where there is misinformation and rumors the cause and origin of the virus and disease its symptoms and transmission patterns available treatments prophylactics and cures and the effectiveness and impact of interventions by health authorities or other institutions researchers in brazil who monitor the advance of fake news have identified that in relation to covid19 they have mainly revolved around these topics politicization of the virus homemade remedies to prevent infection advocacy for the use of chloroquine and hydroxychloroquine and posts against social isolation dissemination of rumors and misinformation is not new there are records of its effect in previous sanitary emergencies such as outbreaks of zika and h1n1 the difference with infodemic is the current context of the information society in which technologies have gained a central social role in information access and the characteristics of the posttruth society in which beliefs opinions and emotions gain prominence over facts in the brazilian context fake news has been used as a political weapon with serious consequences they place lives at risk contribute to the discredit of science and global health institutions and weaken measures to combat the disease once again the destabilizing role played by the brazilian president cannot be downplayed his demeanor for science and defense of controversial measures such as the socalled vertical isolation and the use of unproven therapies as the only available cure stand in stark contrast with measures guided by scientific consensus that are being implemented by governors and mayors across the country this has severe consequences a research conducted following public pronouncements of president bolsonaro in which he defended relaxing social isolation and the importance of prioritizing the economy over lives concluded that social isolation was lower among the presidents supporters states where bolsonaro received more votes relaxed quarantine measures earlier and among the most populous municipalities of the state of são paulo those in which the president had received more votes presented lower rates of social isolation a more recent research still unpublished but widely discussed in the brazilian media reached more disheartening conclusions in cities in which the president had more votes social isolation had been lower and the number of covidrelated deaths had been higher experts have pointed out that fake news and mr bolsonaro ´s actions and declarations are hampering strategies to combat the pandemic as the exminister of health dr luiz henrique mandetta fired by bolsonaro in april 2020 in the midst of the health crisis declared the population does not know whether to listen to the minister of health or to the president in addition mr bolsonaro ´s insistence on reopening the economy regardless of the toll might take in terms of human lives creates a scenario in which the population is placed in the contradictory position of having to decide based on false premises whether to protect their health and that of their families or to risk contracting the virus in order to protect their jobs and means of survival the situation poses the question how to act when the democratization of communication and ample access to information result in an enormous load of misinformation fake news and manipulatory and contradictory information that in a certain way are used as a control strategy health promotion and control the pandemic highlighted the need for models that questioned the exclusive role of biomedicine in solving health problems as it became clear how health influences and is influenced by several factors health and life are complex and singular issues the magnitude of which the scientific evidence does not seem to encompass the analysis of the materials selected pointed to a focus on modifying lifestyles that were considered unhealthy risky or inappropriate in a pandemic scenario the emphasis on particular habits reinforces the notion that individuals were solely responsible for their health disregarding economic political and social determinations and at the same time exempting the state from its role as a formulator of public social policies this individualization is strongly influenced by the notion of entrepreneurship in the neoliberal discourse in which people are asked to constantly work on themselves and be selfsufficient there is a reinforcement of the image of the entrepreneurial self who aspires for personal fulfillment understands hisher reality and destiny as individual responsibility regardless of the social structural and political context and with minimal support from the state it is common to hear in the health and education field the phrase i teach but he or she does not learn there are definitions of what is considered adequate and a prejudgment that people are not capable of choosing what is best for them and therefore need to be taught health professionals are often considered the experts on how to mold organize and reorient personal behaviors as such they can indicate solutions to everyday problems and just like that people are expropriated from their own knowledge and capacity to think about their own lives a great deal of the materials that are circulating with recommendations were elaborated based on an ideal middleclass family and focussed on individual action one example is the advice to create a home office for some this is a valid option but for others it creates a dilemma without governmental policies for social protection should they stay home and go hungry or risk going out to earn their wages materials posted on the website of the brazilian ministry of health encourage the population to adopt healthy behaviors during the pandemic they discuss how to maintain a regular meal routine three daily meals and snacks with fresh or dried fruits nuts and seeds without salt or sugar they explain the importance of family meals at a quiet place the therapeutic advantages of cooking and of involving children in such tasks there are orientations about how to not be sedentary it also describes the importance of mental health and the need to maintain high selfesteem and healthy digital relations the material is clearly aimed at a populational group that has access to services housing food income and family and points to a notion of quality of life that is related to personal behaviors the ministry of women family and human rights published tips for parents and guardians on how to talk about the situation with children and adolescents with proposals to take advantage of time at home to strengthen family bonds or play together a booklet with advice for parents homeschooling children with disabilities suggesting they should choose environments without noise or too much stimuli and use resources such as music and videos the material although dealing with diversity places responsibility on parents for the educational process and disregards the entire context of inequities housing and access to the internet local governments have also widely disseminated messages through social media urging people to take care protect your health and that of your family and the hashtag stay at home the examples above ignore the difficulties faced by peripheral and vulnerable communities to adopt measures to contain the spread of the virus and practice social isolation a context analysis of social vulnerabilities in brazil helps to understand that measures considered simple such as handwashing sanitizing objects and packages or staying at home will not apply for all people and yet implicit in the recommendations is the idea that those who get sick are responsible for their fate because they either did not understand the messages or did not follow the instructions in brazil about 136 million people live in slums research conducted by data favela and instituto locomotiva points out that the favelas of brazil have 52 million mothers of these 72 say that their familys food will be affected by the lack of income during social isolation 73 say they have no savings to keep spending without working for a day 92 say they will have difficulty buying food after a month without income of the 10 8 say that their income has already fallen because of the coronavirus and 76 report that with their children at home and not going to school house expenditure has already increased in addition access to basic sanitation in brazilian municipalities is precarious 1638 of the brazilian population approximately 35 million people has no access to water supply 4685 do not have sewage collection coverage and only 46 of the volume of sewage generated in the country is treated how can these populations maintain hygiene measures without access to basic sanitation and water how to remain in isolation if countless people share the same house how to stay at home as many work in essential services and need to guarantee their survival and the conditions for other people to remain in isolation how could they adopt the recommendations from the government to maintain the familys wellbeing at home messages and norms implicit in the recommendations put forward reinforce authoritarian actions on populations that already experience different forms of violence in their daily lives historically informal settlements and their residents have been stigmatized blamed and subjected to rules and regulations that are inaccessible or impracticable to be adopted unlike residents of middle and upperclass neighborhoods residents of peripheries face difficulties to adopt the restriction of circulation since many of these territories are under the control of militias and drug trafficking groups that prevent the closure of commercial activities and local services in these places women are often the ones responsible for activities related to social reproduction and the care of children the elderly and the sick they are also more exposed to contagion by covid19 in the context of confinement many women became victims of domestic violence with little or no possibility of denouncing the abuse or activating their safety nets the brazilian ministry of women family and human rights reported a 40 increase in the number of complaints of violence against women in april 2020 compared with the same month in 2019 health promotion in the defense of life and a solidary future resistance movements and solidarity actions in defense of life have also emerged groups and organizations came together to collectively develop what we call a common plan to support vulnerable people in marginalized areas and create solidarity networks in their territories despite seeming like isolated actions in the midst of the storm these experiences point to the potential of repositioning health promotion as a relevant field to guide the development of responses in times of crisis such as the current one and for the future the media reported on the collective efforts that were taking place in the paraisopolis the second largest favela in the city of sao paulo housing over 100 000 inhabitants and with a population density of 61 000 km 2 the article paraiso ´polis monitors 21000 homes with street presidents and their own doctor describes the community mobilization strategies developed in that territory the initiative started as community leaders realized that public policies would not reach the favelas and decided to create a state within a neighborhood actions included distribution of food and hygiene materials collected from donations and projects to generate jobs and income the group reached 21 000 houses the total number of houses in the community is much higher so they had to develop criteria to identify the neediest families another initiative also reported in paraiso ´polis was the the favela takes care of the favela paraiso ´polis has its own doctors and ambulance as the public emergency medical service did not adequately served the region the residents association hired medical teams and vehicles on its own to rescue patients in need of emergency care during the pandemic this service is part of a contingency plan prepared by the g10 of the favelas to try to control the spread of the virus in the community and offer assistance to families the group set up a crisis office which prepared and distributed lunch boxes and basic supplies produced masks raised donations for day laborers who had lost their income and defined volunteers to monitor the streets in paraiso ´polis funds were raised through online donations results of these initiatives demonstrate the effectiveness of community action on may 18 the covid19 mortality rate in paraisopolis was 217100000 inhabitants which is almost onethird of the average mortality rate of the municipality of são paulo the covid19related mortality rate for the population over 60 years old in paraiso ´polis has also been lower than that of the municipality for this risk group which indicates that the region despite its social vulnerabilities was able to better protect their elderly this experience suggests that actions that consider the real needs and specificities of the population and actively involves the community are powerful triggers of the caring dimension of health production this is a good example of pandemic control that could be replicated as a state policy to other vulnerable territories in the country another initiative was that of brazilian organizations that joined social media campaigns to form a solidarity movement to protect vulnerable women one initiative was the vizinhavoce ˆnãoesta ´sozinha aimed at encouraging women to speak up about gender violence channels and hotlines were made available to receive complaints and support women who were victims of violence in july 2020 health organizations conformed the movement for life in the form of a manifest geared at public authorities and society the document urges the strengthening of social protection systems and measures to protect vulnerable populations and human rights and reinforces that science and society can produce alternative responses to the countrys chaotic sanitary situation the manifest urges the consolidation of intersectoral actions in all areas that impact the social determinants of health and a system to monitor the life conditions the most vulnerable populations it is a political manifesto in defense of life and a call to social responsibility particularly from public authorities in light of the countrys racial and social inequalities it calls for a renewed and expanded social contract that prioritizes the specificities and demands of vulnerable and oppressed populations with health as a central value this could constitute the true legacy of the covid19 pandemic these are some examplesand others could be addedof how to unleash potent healthpromoting practices beyond what is already acknowledged by health promotion researchers and lead to the construction of a common calling this common is not meant to delegate more responsibility to subjects and social groups for their wellbeing but as an eminently political concept that intends to expand the autonomy and power of local actors and management bodies consider the territorial dynamics establish pacts and local partnerships and foster participation and intersectoral action solidarity therefore assumes an ethical character and takes the form of support among people places and collective projects solidarity is the reciprocal connection or interdependence which implies understanding it from a perspective of diversity and otherness this characteristic is reinforced by the ability to put oneself in the others place get in touch with life stories and experience together with people feelings that are ambiguous and intense conclusion how could health promotion be a framework to guide efforts to tackle the pandemic in the brazilian we pointed out that the situation generated a wealth of information and strategies that were not always consistent with the brazilian economic social and cultural diversity and in general were aligned with a prescriptive and normative model of behavior these strategies risk transferring to individuals the responsibility for overcoming adversities dislocating the focus of the political dimension of the pandemic and limiting it to individual actions health promotion framework had little relevance in the construction of mainstream strategies in brazil yet it was present in propositions generated by civil society strategies that promote equitable health conditions face many challenges in brazilian but there is hope and potentialities that strengthen health promotion as a reference for the defense of life while the current brazilian conjuncture has devastating effects when confronting the new coronavirus it is also enabling the emergence of efforts that reinforce the importance of guaranteeing universal rights it is important to develop proposals for public policies and strengthen collective initiatives that directly affect current needs and demands which are not so new as they reflect the historical structural problems of our society in the words of fiocruz president nisia trindade lima the pandemic is not the same for everyone we are all going through the same storm in the same sea but it is as if some were on transatlantics others on yachts and others on sailing boats or even canoes the experiences presented here highlight the importance of reaffirming health promotion principles that have been reiterated for decades incorporated into the brazilian national health promotion policy and yet do not seem to have the strength to change the statusquo and become a praxis in society intersectoriality collaboration and solidarity ethics as the central value of life the formation of subjects with critical and reflective capacity and the valorization of peoples autonomy and potential in this sense we believe that the greatest advocacy in the field of health promotion at this moment is political and could be directed toward revisiting these principles supporting permanent mobilization against setbacks in the public sphere and defending a new democratic inclusive and collective vision of society

this article discusses how preventive and promotional discourses have been incorporated by the brazilian population in the context of the coronavirus pandemic it analyzes materials posted on the internet and social after the first case of covid 19related death in brazil that are related health promotion and covid19 aimed at orienting societys response to the pandemic the analysis considers two key factors the mismanagement of the pandemic by the brazilian government and infodemic there is complex use of scientific information with recommendations that focus on what people should do intervention and in transforming individuals behaviors based on an ideal model of healthy behaviors narratives aimed to delegate to the population and specific groups the task of taking care of themselves have been reinforced removing from the state the responsibility to offer conditions for the population to address the situation there is a sophistication of strategies that blame individual practices personal organization and that are disconnected from the collective especially for those who live in situation of extreme vulnerability concomitantly there are also discourses based on notions of solidarity and renewed social connections which are empowering and consistent with the practice of health promotion as it attributes meanings to the subjects and their ways of life we conclude that greatest advocacy in the field of health promotion at this moment is political and could be directed toward reaffirming health promotion principles supporting permanent mobilization against setbacks in the public sphere and defending a new democratic inclusive and collective vision of society

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introduction down syndrome is a developmental disorder resulting from an error in cell division 95 of cases involve an extra copy of chromosome 21 while in the remainder either the extra copy occurs in some cells or parts of chromosome 21 attach to another chromosome 1 down syndrome is the most common genetic cause of intellectual disability impacting approximately one in every 691 live births 12 this condition is associated with specific physical features medical conditions including congenital heart disease and intellectual disability individuals with down syndrome also meet academic challenges or delays in all facets of education in addition to intellectual disability the ds neuropsychological phenotype is characterized by specific neurocognitive impairments especially in the domains of language 3 according to potier reeves 4 congenital intellectual disabilities such as ds originate from the earliest stages of development acquisition of cognitive skills and thus this occurrence results in neurodegenerative pathologies which are cumulative with respect to communication and language infants with ds show delays in oral language skills which have additionally been linked to reading in canada there are 45000 individuals with down syndrome 1 examining the clinical picture of individuals with ds it has been reported that complications may be exacerbated by the presence of functional deficits behavioral symptoms nutritional and social problems all of which have increased prevalence with age 5 sociality and social interactions are important for individuals with ds who identify family involvement and affection as main supporting pillars in life 6 early researchers have noted that students with down syndrome have unique learning needs due to delays with communication academic functioning and comprehension abilities 7 evidence also suggests that life expectancy for this population and those with developmental disabilities is nearly 20 years below that of the general population and mortality is significantly higher across their lifespan 8 gap in existing evidence for participatory action research and ds there is comparatively minimal published research that transparently charts the contribution of youth with an intellectual disability within a collaborative research process this is supported by evidence presented by st john et al 9 who reported that participant action research methodologies may empower and protect marginalized individuals however they remain underutilized limited studies have investigated the impact of participatory action research specifically on individuals with an intellectual disability 9 according to schwartz et al 10 including individuals with intellectual disability bring a stakeholderengaged inclusive research approach this may foster and enhance community collaborations more importantly this may optimize these relationships and support the involvement of people with id in stakeholderengaged research projects within our communities this collaborative multistakeholder approach which aims to engage individuals with intellectual disabilities can be an effective model for conducting research this was well documented within recent findings from jose et al who examined participatory research with adults who had autism autistic adults and their caregivers can make the research process more open and accessible and make its outputs more relevant useful and meaningful to the wider autistic adult community within research selfadvocates have expressed the key concept being that they are the stakeholders with the most at stake for enhanced communication education and community engagement 11 youth engagement during this par 6 youth with down syndrome were active participants who engaged in various community social inclusion activities which aimed to offer opportunities for communication that focused on creative and visual arts sessions included painting clay song writing and photo collage creation as hartigan et al 12 explained additional and reimagined arts education programs in schools can incorporate creative arts therapies these practices can be a valuable tool for youth with disabilities using these methods of creativity to support expression participants designed various pieces of art and shared the meaning within the local communities community sharing sessions included the local university police station performing arts stage school and online with invited special guests down syndrome and communication according to a study completed by wilson et al 13 results indicated that 978 of participants with ds met criteria for speech disorders and 978 met criteria for motor speech disorders including childhood dysarthria speech motor delay childhood dysarthria and childhood apraxia of speech and childhood apraxia of speech ataxia was the most prevalent dysarthria subtype nearly all participants with ds in the present sample had some type of speech and motor speech disorder 13 the national down syndrome society 14 explained that research and clinical experiences demonstrated that some areas of language are generally more difficult for children with down syndrome while other areas are relatively easier children with down syndrome have strengths in vocabulary and pragmatics they often develop a rich and varied vocabulary as they mature they have good social interactive skills and use gestures and facial expressions effectively to help themselves communicate however while auditory shortterm memory and auditory processing can be areas of weakness children with down syndrome often have excellent visual memory according to the national down syndrome society 14 most children with down syndrome can understand much more than they can express as a result their test scores for receptive language are higher than for expressive language this is known as the receptiveexpressive gap speech intelligibility is one of the most difficult areas for people with down syndrome at all ages many children have difficulty with the strength timing and coordination of muscle movements for speech speech involves coordinating breathing voice and the production of speech sounds 14 results indicated that students with down syndrome had basic narrative skills that were weaker than typical students of the same age students faced challenges with comprehension and recognizing various concepts it was concluded that typically developing students progressed and used these skills at an early age while students with down syndrome were delayed and possessed weaker skillsets the findings also discussed the variance in learning abilities and the need for specialized training to assist youth with down syndrome 15 this suggested an important direction for future research within the field of down syndrome and communication strategies using various visual schedules can improve or enhance learning for students with down syndrome in another study bauer et al 16 also studied students with down syndrome and communication interventions the researchers designed a multiple baseline probe design which explored several components of responses such as the effectiveness of multiple opportunities prompting reinforcement and error correction procedures a baseline was conducted for both children strategies implemented by teachers and a follow up analysis the overall results determined that when the students were taught simple communication skills such as verbal imitation an improvement in effectiveness of communication occurred 16 discussion utilizing creative and visual arts as a method of research can engage youth with id in artbased interventions to support individual communication creative arts have supported people with id for decades advancing research to include the firstperson lived experiences of young people with id is imperative as this form of research which includes youth has positive outcomes for research practice and the individual themselves 17 this practice can promote opportunities for social interaction and emotional expression are especially valuable for people with difficulty communicating verbally approximately fifty percent of creative arts therapists work with children young people and adults with intellectual disabilities 18 seminal researcher sue buckley was among one of the first early investigators to connect the importance of creativity and communication for individuals with ds 7 participants in this study utilized several forms of creative art to enhance personal communication using photo voice to create a story photo collage to describe experiences and song writing to express key concepts of social inclusion were essential aspects of creative and visual arts used by participants creative expression through the arts may be especially important for children and adults with down syndrome for several reasons first most will have major difficulties in expressing themselves through spoken language through talking or writing additionally many cannot share their feelings through words but can do so most eloquently through dance and movement or through painting 7 initiatives such as photovoice where the participants use and direct the camera and participate collaboratively in the inquiry process can become a creative engaging and empowering enterprise with much potential for enacting change 19 collage is the practice of collecting important materials then cutting tearing folding or crumpling these remnants taken from preexisting pictures found objects or fabrics or a mixture of these and gluing them onto a flat surface to communicate a visual message 19 providing youth with ds an opportunity to express themselves using a variety of creative art modalities may assist overall expression collage can be used as a method for individuals to reflect and understand the research process thus assisting in methods to share their thoughts and experiences collage can help individuals to understand the hidden research process in a way that aids in conceptualizing the understanding that might otherwise remain implicit 19 for those with a disability the utilization of creative arts can promote coping and resilience as well as providing opportunities for escapism creativity spontaneity and enjoyment 20 the creative arts therapies can increase awareness of emotions and enhance capacity for emotional expressions 21 participants within this study utilized various forms of creative art to express thoughts feelings and emotions story telling of events were also vital for those participants with limited verbal speech within this case participants used photos with oneand twoword phrases to describe an event or activity which was important for them using various modes of creative art for communication was successful and engaging for youth with down syndrome living in nova scotia canada 22 conclusion with respect to both social and educational development a precursor to success is acceptance of individuals with down syndrome 23 the academic foundation of this research will allow the community to move beyond practical and functional aspects of this type of participatory action research to understand how community dynamics relationships and communication play a central role in creating socially inclusive opportunities through creative arts 24 six youth with down syndrome engaged within various modes of creative and visual art as a mode to assist with expressive communication during this engagement youth were invited to sing story tell and meet new individuals within the community 25 photo voice photo collage and song writing were examples of creative arts utilized to share feelings and experiences during and after periods of isolation during covid19 26 results of the research indicated that utilizing creative art modes provided individuals with down syndrome an expressive opportunity for communication 27 conference proceedings conflict of interest no conflict of interest

this participant action research project par was a collaborative qualitative research project which explored creative and visual arts as a method for social inclusion and communication six youth with down syndrome ds from nova scotia were participants this active participation within a creative and visual arts modality explored and share individual experiences from participation in a social inclusion project during the covid19 lockdown period youth experienced community song writing creative dance photo collage and photo voice sessions as a mode of expressive communication the project aim was to establish an increased awareness and knowledge specific to the achievement gap and understand various modes of expression and communication practices for youth with disabilities additionally examine how creative and visual arts could aid within overall expression for youth with down syndrome limited research is available which supports par for youth with intellectual disability six participants are striving to close the academic and social achievement gaps they experience every day inequities faced by students with intellectual disability id have been documented and explored in recent results indicated that feelings of belonginess were expressed during creative arts sessions and acts of empathy throughout various art projects were documented in addition data suggested that exposing youth to new methods of communication and expression can promote community engagement and social inclusion for youth with disabilities

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manner people show the same tendencies 2 ideally humans would interact with robots as naturally as they interact with other people to facilitate this kind of social interaction robot behavior should reflect lifelike qualities since this early vision of human social interactions with robots the relationship between on the one hand the lifelike qualities of a robot and on the other hand the human tendency to anthropomorphizeie to treat the robot as an individual with humanlike qualities and mental states has been a subject of intense investigation in social robotics and hri while the past one and a half decades of hri research have revealed the complexity of the phenomenonshowing dependencies on eg sensory modality framing of robot interaction context or personalityin the course of these investigations the terminological clarity has become challenged this is partly due to an ambiguity of the noun anthropomorphism which carries different meanings for different researchers thus while some take the noun to denote the human tendency to anthropomorphize for others the noun belongs with the adjective anthropomorphic and characterizes the appearance of a robot as assessed by the roboticist moreover the scope of the anthropomorphic features of a robot as characterized in descriptions of experimental setups varies between lifelike and humanlike while anthropomorphizing focuses on exclusively humanlike capacities the potential conceptual and methodological problems introduced by this ambiguity of the term anthropomorphism do not seem to have received much attention 4 in fact occasionally formulations displayor at least inviteterminological confusions for example a study investigating the human tendency to anthropomorphize a certain device is announced as a study on anthropomorphism of a receptionist robot or again authors investigate reactions to an anthropomorphichumanlike robot but describe their target as human impressions and behaviors toward anthropomorphized artifacts in addition while an extensive analytical research debate about the content and implications of the descriptor humanlike appears to be missing a host of different measures of human reactions are in use suggesting implicit conceptual variations given the centrality of the phenomenon of anthropomorphizing for social robotics it is important we submit to investigate whether observations of terminological uncertainties should be counted as sporadic linguistic infelicities or should be taken to be indicative of a more pervasive methodological problem a scoping review can help answer this question as this method offers a panoramic summation of evidence for a given research question 7 a scoping review can have various objectives presently the focus is on describing the definitions assessments and conceptual understandings of anthropomorphism as used in hri research thus the scoping review does not offer an answer to the specific question of what anthropomorphism is and how it should be assessed but rather describes the empirical and conceptual landscape within the field that the focus on anthropomorphism is of central methodological significance is also borne out by most recent developments of classificatory tools metaanalytical synopses 9 or measuring techniques 10 for human reactions to robots that are focused on or include anthropomorphism the significance of these proposals hinges on whether the notion of anthropomorphism that is modeled in these contributions captures deviates from or improves on the understanding of the term anthropomorphism in state of the art of hri or social robotics research here a scoping review can provide useful clarifications for instance onnash and roesler 8 offer a taxonomy for humanrobot interaction that operates with three classificatory dimensions the interaction context the features of the robot and the team classification ie a classification of the interactional roles performed by the human interacting with the robot this classification helpfully provides predefined categories to enable structured comparisons of different hri scenarios and thereby enable a more differentiated discussion of studies on human reactions to robots as well as of some studies on the phenomena labeled anthropomorphism in the literature but the scope and thereby also the relevance of the proposed classification is not discussed for this purpose one would need to clarify whether the specification of interactional roles is sufficiently strong to cover phenomena of anthropomorphizing at more finegrained levels of human experience as well as whether such more finegrained differentiations of the human tendency to anthropomorphize have been considered an important investigative target in the anthropomorphism literature in hri our study here can clarify this latter task which is prerequisite for evaluating the scope and relevance of the suggested taxonomy in application to hri research on anthropomorphism its prime illustration in short scoping reviews can usefully support the evaluation of constructive proposals for new definitions or models of a theoretical construct with these auxiliary functions in mind we thus present a scoping review of relevant contributions to hri research in order to arrive at a better understanding of the methodological status of anthropomorphism a key notion of current hri research as our results show greater attention to the definition and use of the term anthropomorphism is not only required for the sake of good terminological housekeeping but also promises broader methodological advancement providing new leads towards development of improved and standardized measures a similar endeavor was recently undertaken in a review of anthropomorphism in ai enabled technologies where the authors conclude that there is a need for theoretical and operational clarity of the concept of anthropomorphism unfortunately it is not clear to what extent the conclusions extend to research on embodied technology 11 recent models and identification of points of contention in the employment of the term anthropomorphism that call for clarification 12 document an increasing perception among hri researchers that it is time to critically reflect this central theoretical construct of hri research while individual literature reviews may also offer important insights for this purpose a systematic scoping review anchors the assessment of conceptual divergences with greater empirical validity research questions the main research questions governing this scoping review are as follows 1 how is the notion of anthropomorphism understood in hri and social robotics research 2 which assessment tools are used in hri and social robotics research to assess anthropomorphism while hri and social robotics research are characterized by different targets and methods we will for ease of reference in the following use hri to cover both areas methods the protocol of the present scoping review was preregistered in cadima an opensource evidence synthesis tool three electronic bibliographic databases were searched for relevant publications ieee compendex and acm digital library in march 2021 the search strategy was established through team discussions and finally reviewed by an experienced librarian the final search string drew on the spider criteria s pi d e r 13 given the variety of research designs utilized in hri the spider criteria were a better match for the goal of the present review than the more familiar pico criteria mainly used in intervention research or the pcc criteria more often used in scoping reviews to increase the likelihood of identifying all relevant records we did not include definitions ofsample orresearch type in the search string however forsample we specified that children should not be included hence the final search string encompassed keywords on s pi d e the search strategy was employed for each of the three electronic databases independently using the boolean operators due to different technological interfaces subtle differences in the search string had to be introduced into the search string to capture all relevant publications in each database for the full list of search strings see appendix 1 following the search in the databases all the identified publications were exported to the referencemanagement software zotero imported into cadima and were first screened at the title and abstract level independently by two authors in accordance with the inclusion and exclusion criteria to be detailed presently an initial consistency check was conducted after n 30 records to ensure that the ratings were consistent by the two raters following the abstract and title screening the remaining publications were full text screened independently by the same two raters reasons for exclusion were noted for each excluded publication at both the abstracttitle and full text screenings and any disagreements on eligibility were discussed and resolved within the group of authors we used the following inclusion and exclusion criteria to set the boundaries for the review to render inclusion in the present review the following inclusion criteria had to be met the study should include healthy adults interaction with a physical robotic agent with some movement or acoustic ability that enable direct interaction explicit reference to the notion of anthropomorphism and a systematic assessment of the human disposition for projecting human characteristics onto the agent an empirical investigation including controlleduncontrolled trials case studies focus groups interviews surveys experiments writing tasks field studies etc published as an empirical research paper or extended abstract in peerreviewed journalsproceedings vi published in english studies meeting any of the following criteria were excluded studies with adults with severe cognitive impairment use of a nonphysical agent or telephone or standalone virtual agents unless used as a comparative condition to a physical robotic agent assessment of anthropomorphism´solely as an intrinsic quality of the agent narrative or systematic reviews research protocols grey literature short conference abstracts critical appraisal the included studies were quality rated in line with the methodology for conducting scoping reviews the aim of critical appraisal is to systematically identify strengths and weaknesses in the included records and make visible any potential sources of bias 15 in the development of appraisal criteria for the present review we sought to embrace the diversity of research traditions from which the included studies stem given the heterogeneity of the research methods employed within hri research we could not adhere to any of the full critical appraisal tools traditionally used but strived to use subitems that the tools share with one another thus the following criteria were assessed on a threepoint rating scale is the research question or aim clearly stated is the recruitment strategy appropriate for the research aim have basic characteristics of the population been described is the procedure well described was sample size determined based on a priori power analysis did it include a welldefined description of the assessment of anthropomorphism did the authors report on potential conflicts of interest in total the critical appraisal rendered a maximum score of 14 data extraction from each included record we abstracted data on publication characteristics sample characteristics research design research hypothesis overall results definition of anthropomorphism utilized in paper assessment tool for assessing anthropomorphism and robot characteristics importantly data was only extracted if it pertained to anthropomorphism thus data extraction was only performed on the research hypothesis and assessment tools that related to anthropomorphism from the included records results the literature search in the three databases yielded a total of n 2031 records as seen in the prisma flow diagram in fig 1 after duplicates were removed 1499 records remained an initial consistency check was conducted for the screening of the first 30 records yielding an excellent kappa value of 084 1 following title and abstract screening a further 1329 records were removed as not compliant with the above stated selection criteria leaving 170 for fulltext screening following the fulltext screening an additional 113 records were excluded leaving a total of 57 publications included in the present review sample and study characteristics for an overview of the characteristics of the 57 included records see table 1 in total the 57 included publications encompassed n 2947 participants whereof n 1082 were male and n 1277 were female the genders of the remaining participants were not disclosed in the publications thirtynine of the 57 publications reported the mean age of the participants the mean age across these publications was 2714 years standard deviations were disclosed in 25 publications importantly the lower age range was predefined by the inclusion and exclusion criteria in the review in 17 publications it was not explicitly described how the participants were recruited 19 of the studies recruited amongst the student population and 21 studies had other recruitment procedures the majority of the included publications encompassed laboratory studies whereof 34 had a between subjectsdesign 11 had a withinsubjects design 2 were qualitative laboratory studies and the remaining one study did not include any comparator four of the included 57 publications described field studies 1 described an fmri study and the remaining 5 studies included other designs most studies were from the continents of asia north america or europe four studies were from oceania and three studies were conducted on multiple continents it was unclear where the remaining 11 studies were conducted as illustrated in fig 2 relative to the pool of studies reviewed there appears to be a surge of interest in researching anthropomorphism given that inclusion of a physical robot is an inclusion criterion for the present review this increase could also simply reflect the increased availability of robots results of critical appraisal the results of the critical appraisal can be seen in table 2 a large proportion of studies do not report on key elements of research ethics in their dissemination of results which makes is difficult to ascertain to what extent participants could have been coerced or could have entered the study on an uninformed basis only three of the 57 studies reported on potential conflicts of interest declaring conflicts of interests is particularly important for research undertaken by institutes from the private sector but conflicts of interest should be declared regardless of whether they are present or not and independently of the journals policy to support this element of research methodology explicitly in the course of the submission procedure for some studies it was difficult to determine if the recruitment strategy was appropriate to obtain the kind of knowledge necessary to answer the research question this was due to inadequate information on how the participants were recruitedwho or how many chose or refused to partake after being asked how potential participants were approached how and if they were compensated for participation and so forth for instance it remains unclear if results might have been influenced by whether students were approached directly in class by their own lecturer and whether compensation via course credit raffle tickets or monetary reward could have affected motivations additionally only four of the reviewed studies based recruitment on a priori sample size calculations hence it is difficult to ascertain if the studies have sufficient statistical power to ensure that effects did not occur by chance the description of some basic characteristics of the participation pool and of study procedures were more detailed importantly however we approached question 4 very leniently and only required the studies to report some descriptive information on the participants with very few exceptions the research goals and descriptions of how anthropomorphism was assessed were adequately reported types of robots used in studies assessing anthropomorphism an overview of the robots included in the studies can be seen in table 3 a total of 43 different robots were usedranging from robots with entirely nonhumanoid physical shape and interaction repertoire designed only for functionality to robots with humanoid physical shape and interaction repertoire explicitly designed for social interaction with humans besides commercially available robots some studies used robots constructed by the researchers themselves the single most frequently used robot in the included studies is softbanks nao robot the vast majority of studies included only a single robot four studies included interaction on screen as a control condition in their experiment six studies used humans as a control condition how anthropomorphism is defined very broadly speaking the included records can be sorted into five categories relative to how they approach the task of defining anthropomorphism as can be seen in table 4 the dominant approach seems to be to use term anthropomorphism without defining it on the implicit assumption that a shared conceptual consensus exists the second most common approach consists in using and quoting the definitionor minor variations thereofoffered by epley and colleagues 72 imbuing the imagined or real behavior of nonhuman agents with humanlike characteristics motivations intentions and emotions is the essence of anthropomorphism these nonhuman agents may include anything that acts with apparent independence including nonhuman animals natural forces religious deities and mechanical or electronic devices for ease of reference we label the various definitional strategies relative to the focus of the definition since the focus of the second approach is on anthropomorphism as attribution we call this definition the attributionfocused definition some studies adhere to the attributionfocused definition but elaborate it by highlighting specific functions of anthropomorphism for instance that anthropomorphism acts as a hypothetical mechanism of inverse dehumanization 27 or that it increases the ability to predict and explain the behavior of nonhuman agents 17 the socalled effectance motivation factor from the model of anthropomorphism suggested by epley and colleagues 72 others elaborate some aspects left open by the attributionfocused definition accentuating for instance that the apparent independence is a form of acting that allows the human user to take the socalled intentional stance of interpretation ie to view the behavior as intentional 66 0 2 0 2 2 1 2 18 0 2 0 2 2 2 1 19 0 2 1 1 2 2 1 2 20 0 2 0 2 2 2 0 21 0 2 0 2 0 2 1 22 0 0 0 2 1 1 1 23 0 2 0 1 2 2 2 24 0 0 0 2 2 2 1 25 0 2 0 2 2 2 2 26 0 1 0 2 2 2 0 27 0 2 0 2 0 2 1 28 0 2 0 1 2 2 1 29 0 2 0 2 2 2 1 30 0 2 0 2 2 2 2 31 0 2 0 2 2 2 2 32 0 2 0 2 2 2 2 33 0 2 0 2 2 2 2 34 0 2 0 2 0 2 1 35 0 1 0 0 2 2 0 36 0 1 0 2 2 2 0 37 0 2 0 2 2 2 2 38 0 2 0 2 2 2 1 39 0 2 0 2 2 2 1 40 0 2 0 2 2 2 1 41 0 2 0 2 1 2 2 42 0 2 0 2 2 2 1 43 0 2 0 2 2 2 1 44 0 2 0 2 2 2 1 45 0 2 0 2 2 2 2 46 0 2 0 2 2 1 2 47 0 2 0 0 2 1 1 6 0 1 0 2 2 2 2 48 0 1 0 0 0 2 1 49 0 0 0 0 1 2 1 50 0 0 0 2 2 2 2 51 0 1 2 2 2 2 1 2 52 0 2 0 2 2 2 1 53 0 2 0 2 2 2 1 54 0 2 0 2 2 2 1 55 0 2 0 2 2 1 1 2 56 0 2 0 2 2 2 0 57 0 1 2 2 2 1 1 2 58 0 2 0 2 1 2 1 some researchers define anthropomorphism as a noun that relates to the predicate anthropomorphic understood as denoting a quality of the physical shape of a robotlets call this the robotic featurefocused definition and test to what extent participants ascribe this quality by way of assenting to commonsense descriptions such as humanlike shape or humanlike appearance occasionally on this understanding of anthropomorphism as a characterization of robotic features behavioral features of the robot are also included as for instance seen in the following passage anthropomorphism of an entity refers to how humanlike it is in appearance or behavior another common approach which we call the definition by imported construct is to cite the publication from which the godspeed questionnaire series stems in order to import implicitly or explicitly the definition of anthropomorphism stated there anthropomorphism refers to the attribution of a human form human characteristics or human behavior to nonhuman things such as robots computers and animals so the definitional focus of the gqs questionnaire is not sufficiently narrow to be classified as an attributionfocused definition of anthropomorphism a few studies offer definitions that seem to be inspired by one or more of the aforementioned approaches but end up operating with idiosyncratic modifications or combinations without anchoring these in citations this strategy we label narrowed attributionfocused definition for instance ono and colleagues define anthropomorphism as …the idea that an object has feelings or characteristics like those of a human being in other words it means that humans regard the object as a person to communicate with and moreover try to read its mind other researchers idiosyncratically introduce a focus on the process of anthropomorphism and characterize it as a psychological mechanism that serves to increase predictability and reduce uncertainty 36 this strategy we call the processfocused definition finally some authors emphasize special functional aspects of anthropomorphism operating independently of epley et al and thus in effect combined with other devices please note that some studies utilized more than one robot whereby the number of robots used exceeds the total number of studies included pursuing a different strategy which we call the functionfocused definition for example here we find the claim that by ascribing intentions to robots it would also make it easier to form social connections with nonhuman agents extending our fundamental desire for social relationships outside of humankind thus anthropomorphism would appear to offer us a simpler more familiar world that is richer in social interaction giving us greater confidence in our interactions with it altogether then the 57 hri studies reviewed here do not proceed from one universally agreed upon standardized definition of anthropomorphism but state their research focus in different ways with at least six semantically significant variations how anthropomorphism is assessed an overview of the questionnaires used to assess anthropomorphism can be seen in fig 3 and table 5 most commonly studies amended existing questionnaires to accommodate a given study objective this was for instance achieved by selecting specific items from published questionnaires adapting scales to a given culturerobot or language or changing the rating scales of a given survey from eg a 7point scale to a 5point scale etc of the 26 studies that amended existing versions of questionnaires 10 did not include other measures of anthropomorphism overall 31 of the studies included only one anthropomorphism questionnaire while 17 of the included studies included two questionnaires and nine studies included three or more different questionnaires ten studies solely assessed anthropomorphism with questionnaires developed for the specific study method 1 assessing anthropomorphism with standardized measures as can be seen in fig 3 the single most used standardized assessment tool in the included studies is the gqs the gqs is based on a collection of amended items from other questionnaires 75 the publication in which it was first presented 75 did not include a factor analysis but high cronbachs alpha scores for the subscales were reported cronbachs alpha scores is a measure of internal consistency of a testie the extent to which there is homogeneity or consistency between individual items the popularity of the gqs is likely due to its availability ease of use and the claimed breadth of concepts being assessed by the scale 89 the scale is designed to assess five composite scores where each is assessed by three to six items on fivepoint semantically differential rating scales the subscale relating to anthropomorphism consists of five items 75 the gqs does not assess the attributional beliefs that a person has when engaged in interaction with a given robot but rather assesses the direct impressions that participants have of the properties of a given robot upon immediate perceptual encounter thus it cannot be used to draw inferences about anthropomorphism as a human dispositional trait 8990 furthermore the construct validity of the scale has been called into questionfor instance it has been reported that the constructs are not represented independently of negativepositive affect and that there are high correlations between subscales indicating a shared underlying factor thus ho and colleagues suggested an alternative scale that they pose as a new measure for human perceptions of anthropomorphic characters that reliably assesses four relatively independent individual attitudes the humanness index from this scale has been utilized as an indicator of anthropomorphism in some of the included studies the humanness index is also a semantic differential rating scale with some overlap with gqs it consists of 6 items and shows good psychometric properties 83 carpinella and colleagues 81 also drew attention to psychometric issues abbreviations and references gqs the godspeed questionnaire series 69 human nature attribution 70 71 72 73 idaq individual differences in anthropomorphism questionnaire 74 rosasthe robotics social attributes scale 75 mind perception 76 humanness index 77 ipipinternational personality item pool 78 inclusion of other in self scale 79 please note that some studies utilized more than one questionnaire whereby the number of questionnaires used exceeds the total number of studies included with the gqs and developed the robotics social attributes scale which builds on gqs items but also includes items from social cognition research unlike gqs and the humanness index rosas consists of unidimensional items that are to be rated in a ninepoint likert scale the items in rosas load on three factors warmth competence and discomfort rosas was used in five of the included studies where the factors warmth and competence have been used in assessment of anthropomorphism however although some authors use subscales of the rosas as an assessment tool of anthropomorphism it should be empirically established if and how the subscales warmth and competence relate to anthropomorphism as rosas was not developed with the purpose of assessing anthropomorphism four studies used the mind perception scale developed by grey and colleagues 82 like rosas this scale is also unidimensional but it distinguishes between attribution of capacities relating to experience and agency participants are asked to compare agents on the various itemseg comparing which agent is more capable of feeling pain the comparisons are made on fivepoint rating scales table 5 standardized questionnaires used to assess anthropomorphism in the included records established questionnaires used to assess anthropomorphism in the included records attribution of mind 80 19212253 gqs 69 161718 20 24 26 27 32 3437 39 41 51 58 60 62 human nature attribution scale 70 71 72 23 48 5355 63 64 humanness index 77 63 64 65 idaq 74 151939 63 64 65 inclusion of other in the self scale 79 20 ipip 78 62 rosas 75 3945515355 several papers used the human attribution scale derived from the taxonomy proposed by haslam and colleagues this taxonomy distinguishes between attribution of human nature traits that are universal among humans from those that are uniquely human yet occur with individual differences reflecting learned or achieved qualities whilst the former qualities are believed to be shared with other animals the latter are believed to separate humans from other animals there are several variations of the scale used in the included records for instance salem et al 54 utilized the ten human nature traits as an indicator of human likeness on a fivepoint likert scale with reference to haslam et al 2008 77 whilst zlotowski et al 70 used a sevenpoint likert scale with the same ten items with reference to haslam et al 78 furthermore fraune et al 29 with reference to loghnan haslam 76 only asked participants to assess two of five traitsbut described both human nature and uniquely human traits in their article the human natureuniquely human taxonomy is further elaborated with the addition of animalistic dehumanization and mechanistic dehumanization 79 under the heading of thehumanness scale and is used in one study with a fivepoint likert scale 61 whilst with a sevenpoint likert scale in another 60 the individual differences in anthropomorphism questionnaire is the only questionnaire utilized in the studies that aims to assess anthropomorphism as an inherent individual tendency or dispositional trait of humans thus idaq scores can be obtained before the actual interaction with a given robot and aid in explaining or statistically controlling for individual variation in the tendency to anthropomorphize however idaq has been criticized for including several abstract terms that might challenge its validitysuch as free will and consciousness 9091 method 2 synthesis of assessments of anthropomorphism with nonstandardized measures some of the publications chose to construct their own questionnaires to assess anthropomorphism the heterogeneous choices of measures made quantitative comparisons and pooling of the data challenging thus in order to make this data more accessible we conducted a qualitative thematic analysis of the individual questionnaire items disseminated in the respective publications 9293 the thematic analysis was made through identification and interpretation of themes in the items in these questionnaires 92 the thematic analysis of the items can be seen in the table of themes below discussion as pointed out in the introduction protagonists in social robotics and hri have been proceeding for two decades from the assumption that humanrobot interactions are based on the human capacity or even tendency to anthropomorphize given that the very possibility of building social robots as well as most of the design questions in social robotics depend on human capacities or inclinations that traditionally have been labeled as anthropomorphism it could be expected that hri and social robotics research have put particular focus on the methodology of research on anthropomorphizing as our results show however there are several methodological difficulties that have previously only received limited attention in particular there are four challenges we wish to highlight relating to four central elements of methodological maturity terminological standardization transparency of procedures standardized evaluation alignment of research targets and assessment tools we discuss these four points in the following subsections addressing and in the last subsection terminological standardization aspects of terminological standardization are degree of conceptual integration precision and consistency relative to the scope of this review our results show that research publications on anthropomorphism have several approaches to definitions thus we identified six different definitional strategies ranging from the simple omission of any definition or elucidation to highly idiosyncratic characterizations this creates three substantive methodological challenges that to the best of our knowledge are not commented upon in the literature the first methodological difficulty is conceptual vagueness the most popular of the definitions that are explicitly cited ie the attributionfocused definition by epley et al is far from precise or unambiguous the definition does not provide any details about the process by which anthropomorphizing occursimbuing the imagined or real behavior with certain characteristics left open how such a cognitive process is to work whether the imbued features have the status of or are experienced as fictional or real features and how against initial plausibility we can consider the imbuing of further information to imagined behavior and the imbuing of further information to real behavior indeed to be the same sort of cognitive process moreover while the definition highlights as a necessary or at least critical feature that the nonhuman targets of anthropomorphizing act with apparent independence it remains unclear whether this requirement should be read as the perceived capacity to act independently of some mechanism or programming and thus in a random fashion or as the emphasis on humanlike characteristics would suggest in an apparently intentional motivated fashion items exploring the attribution of personality 1 do you ever project a personality 14 2 please rate the perceived personality of the robot 42 3 how extravertintrovert was the robot 56 4 i felt that roomba has personality i felt that nao has personality 58 5 how would you judge the personality of the robot 59 items exploring the attribution of classificatory predicates that apply to humans only 1 the robot is a 14 2 do you think the robots have a gender does your team ever use he or she 14 3 the robot is items exploring the participants reflection on their perception of the robot 1 i think of the robots as characters 14 2 is it ever useful to project humanlike characteristics onto the robots 14 3 did your impressions of the robot change as you spent more time with it 14 † exact wording not included in the publication some publications contained questionnaires that were developed by the research group but without the items being published in the paper as we noted above three studies in our sample tried to amend the definition by removing ambiguities with respect to some of the aspects and for instance by describing the process as the inverse of dehumanization and requiring the ascription of intentional agency that epleys definition still has been used so pervasively or has been replaced by a mere reference to the term might be explained by the presumption that the term anthropomorphism has a clear definition in other disciplines and thus can be safely imported such crossdisciplinary terminological trust is alas illfounded since both in psychology and anthropology the term is explicitly contested as brought to the fore by the longstanding debate about method in primate ethology the second methodological difficulty arises from the fact that the various definitions used differ in their meanings as already touched on above this is evident in the case of definition 2 which characterizes not a human disposition but robotic physical features or behaviors this ambiguity has been noticed occasionally in the literature furthermore definitions 2 and 3 which each merely speak of attributions of human characteristics to nonhuman objects are sometimes used in combination with definition 1 which unlike definitions 2 and 3 requires in addition that the target of anthropomorphism is an agent whose agency is perceived as being in some fashion independent researchers who exclusively rely upon definitions 2 and 3 would need to provide clear empirical examples for attributions of human characteristics to items that are not agents nor are perceived as agents before extending the reference class of anthropomorphism by the use of a definition that is de facto less restrictive than their quoted sources definition 4 on the other hand introduces further restrictions on the process and the content of attribution according to our illustration for this strategy quoted above 42 the process of anthropomorphizing here occurs if and only if humans try to read its the object of attribution mind in the context of communication which amounts to a substantive deviation from other definitions moreover the content of attribution is restricted to feelings or characteristics like those of a human being such that the object is regarded as a person to communicate with this clause thus excludes from the phenomenon of anthropomorphizing cases of attribution where a subset of human features is ascribed that as such would not suffice for personhood finally definitional strategies 5 and 6 connect anthropomorphism with certain functional advantages or a desire for sociality to the extent that such elaborations are not mere elucidations but are part of the explanatory category they likewise change the meaning of the term and its application conditions relative to definition 1 which as stated in sect 44 with reference to table 4 is the most commonly used definition discussion of methodological transparency the quality rating of the included records in the present review illustrated some challenges in reporting across several studies the field of hri specifically investigating anthropomorphism is in its infancy as the seven different notions of anthropomorphism identified in this review show because of this a lack of conceptual standardization is to be expected further it is also to be expected that such a lack of standardization will be remedied in due course by both an increase in number of studies and literature reviews such as the current one the progression to standardization can be fostered by methodological practices which enable replication of studies on anthropomorphism in the present review we find a lack of a consensus on the target being measured ie anthropomorphism a separate finding is the relatively high percentage of the studies not fully describing their samples in terms of age and gender distribution at first glance the specific demographic constitution of a research sample may seem unimportant for assessment of anthropomorphism however age and gender has previously been found to affect attitudes towards robots and similar psychological aspects of experiences in humanrobot interaction 97 thus to fully be able to understand the extent to which findings are applicable across genders and ages it is important to describe such details this recommendation is in line with a recent review on reporting in hri 98 and is further underlined by the replication crisis observed in several research fields 99 thus not only is it important to arrive at a standardized notion of anthropomorphism such that studies can measure the same phenomenon it is also important that research practices be upheld even if agreement on anthropomorphism is achieved if the research practices of those studies do not lend themselves well to replication one cannot be sure that what is being measured has the effect the studies suggest in medical and social science research exhaustive descriptions of demographic information are usually provided to ensure adequate data to replicate any given study and to enable readers to ascertain the generalizability of the findings furthermore solid descriptions of demographic information also allow for data synthesis across studies and for secondary analysis such as metaanalysis 100 to be conducted this code of conduct does not appear to be fully integrated in the research included in the present review furthermore the cultural and ethnic backgrounds of samples are seldom mentioned even though research indicates that such factors can have great influence on various aspects of the interaction between human and robot 101102 discussion of assessment tools of anthropomorphism in hri hri research is a fairly new research field and as other research traditions before it finds itself in a double bind regarding assessment tools there is a great need for validated and standardized contemporary assessment tools but at the same time the conceptual knowledge on which such measures should be developed needs to be obtained traditionally this conceptual knowledge would at least in part be obtained with the aid of systematic research via for instance questionnaires thus it should be asked are the published assessment tools that routinely are used to gauge anthropomorphism suitable instruments to reflect the way anthropomorphism is understood now in view of the heterogeneity of the current conceptualizations of anthropomorphism and the multiplicity of nonstandardized assessment tools the risk of misaligning research target and assessment tools is considerable in the current situation this is particularly striking in cases where the nulldefinition of anthropomorphism is used ie where researchers proceed from the presumption that the notion of anthropomorphism is a commonly understood technical term of the debate and adopt one of the standardly used questionnaires but the risk of misalignment arises also due to inherent features of the currently available assessment tools for instance several studies have revealed problems with the conceptual validity of the gqs indicating conceptual overlap between animacy and anthropomorphism moreover in one study it was concluded that gqs subscales …are not appropriate as distinct concepts for evaluating anthropomorphic agents furthermore recently kaplan and colleagues reported that the word pairs used in the gqs are not full semantic opposites and that individual biases towards selecting certain scores may influence results 104 however they advocate that gqs is still a valid instrument if the rating tendency of participants and situationspecific factors are taken into consideration 104 it should be underlined that despite the wide use of the gqs the psychometric properties of the scale are largely unknown however with regard to the psychometrically tested questionnaires such as rosas and the humanness index it is often the case that validation of scales is conducted online 123 with videobased stimuli material in such studies we see impressively large sample sizes and statistically viable and appropriate testing but unfortunately it remains uncertain how results can be replicated in a reallife setting it is conceivable that the response behavior of participants will change depending on whether it is a reallife setting or online study and it cannot be dismissed that not only the magnitude of responses will change but also the way in which responses are distributed within and across factors thus questionnaires that are solely developed and psychometrically tested in an online format should ideally also be reassessed in settings where participants engage in direct interaction with a robot a great number of the included records adapted existing questionnaires and often without describing how they were changed this is problematic as the transparency within and comparability across studies is reduced and the psychometric properties of the scale are potentially changed this is also the case if the answer format of a questionnaire is changed or if items are omitted from a questionnaire for the studies that translated and adapted questionnaires into other languages it is important to describe this adaptation process in order to assess equivalence between questionnaires for instance the actual meaning of a questionnaire item can be inadvertently changed by verbatim translation this is beautifully illustrated by hox who showed how the verbatim translation of happiness from english to dutch would lead to an examination of luck as the dutch word for happiness encompass both luck and happiness thus in such an example results would be difficult to compare the scarcity of validated psychometrically tested questionnaires combined with the increased complexity of the phenomena pursued in hri research are likely the source of the wealth of questionnaire items being designed for specific studies the thematic analysis of these items reveals the great bandwidth of the current understanding of the term anthropomorphism thus the questionnaire items vary in complexity and targetranging from ascription of cognition emotion agency responsibility relational feelings etc to estimation of human likeness of appearance voice and behavior this heterogeneity in the assessment of anthropomorphism in and of itself increases the possibility of misalignment of research target and assessment tool and challenges the possibility of comparing studies as they might not tap into the same aspect furthermore some of the developed questionnaires may unfortunately be very difficult to interpret and utilize across studies for instance several of the questionnaire items refer to complex and vague concepts vagueness introduces error in measurement as variations in the understanding of a given item may result in measurement error within and across studies that are thus due to variations in understanding rather than true differences for instance one item reads on a scale of 1 to 5 5 being extremely human how human did you find the robots behavior 16 without delineating however how behavior should be construed likewise several studies refer to personality will intelligence mind which are all vague theoretically derived concepts given the complexity of these concepts it is unlikely that the ascription of eg will to a robot can be fully explored by a single questionnaire item in other cases it is not the vagueness of the concepts posing a challenge for alignment but also the overall formulations of items as they render answers potentially irrelevant for the research target of the study for example item vi1 do you ever project personality may be intended to gauge the participants selfreported tendency to anthropomorphize but since nature and target of the projection are left unspecified participants may report on their perception of human interagents a different but related set of problems arises due to the fact that social cognition is a highly complex affair which we intuitively navigate without being guided by differentiated common sense terminology an item that explores whether a participant is sorry that x did not achieve y does not allow the researcher to clarify whether the participant felt affective empathy or sympathytwo different emotional states with different implications for the moral status of the robot 106 similarly consider the last sentence in viii1 i am proud that eddie did not guess my person indicating the level of pride in winning over the robot this item can reveal that the participant has cognitive empathy but it does not need to be an indicator for anthropomorphism since the participants may also report here selfcentered pride about their victory over an agent without any human characteristics suggested reporting guidelines based on the discussion of the previous section where we highlighted challenges with conceptual consistency conceptual vagueness methodological transparency and alignment of assessment tools in current hri research on anthropomorphism we propose a series of reporting guidelines the guidelines sum up what researchers are advised to include in their publications based on the scoping review to increase transparency and replicability thus they are similar to overall guidelines on how to report on research but may still be a beneficial checklist for such a young research field this is offered in a constructive spirit as an effort to assist further research and the guidelines should be construed as are all measures described to an extent that the experiment could be replicated is there alignment with how anthropomorphism is defined and how it is assessed is there an explicit discussion about how the assessment questions align to the definition of anthropomorphism used in the study possible interfering factors could factors relating to the robot the experimental design or similar influence the results draft guidelines to be informed and amended by future discussion and research limitations several limitations should be underlined firstly the conceptual unclarity that characterizes anthropomorphism also spills into the review as we utilized the search term anthro which does not necessary pick up studies that examine related terms such as tendency to ascribe emotion sociality interaction potential or similar furthermore the distinction between anthropomorphism and related but likely conceptually distinct terms such as social presence familiarity and animacy is also unclear secondly for purely practical reasons we had to limit our search to publications in english whereby important contributions in other languages could have been missed thirdly many of the procedures utilized in the present review originally stem from medical sciences and intervention research hri research is a relatively new highly interdisciplinary research field and as such represents many different research traditions that are challenging to fit into the template offered here fourthly we focused on assessment of anthropomorphism via questionnaires thereby excluding other research tools future reviews could focus on how anthropomorphism is assessed with other assessment tools such as neuroimaging techniques eye tracking equipment and similar methods finally the review was narrowed in several ways for instance children were excluded because assessment tools developed for children might be difficult to compare to and create synthesis with assessment tools developed for adults furthermore due to the risk of interference on results from severe cognitive decline we also excluded studies with clinical samples furthermore we included only studies in which participants directly engaged with a physical robotic agent with some movement or acoustic ability whereby direct interaction was possible sharing a physical space with an embodied agent has been shown to evoke phenomenologically different experiences that are difficult to compare to simply engaging in interaction via screen or observe prerecorded interactions 107109 however in order to explore the full breadth of the conceptual understanding and methodological operationalization of anthropomorphism future reviews should also explore these aspects conclusion the scoping review presented in this paper examined the definitions reporting practices and primary assessment tools ie questionnaires of recent work in hri research on anthropomorphism revealing that this research target is not fully mature in conceptual and methodological consistency and precision given the complexity of human interactions with robots it is hardly surprising that the conceptual landscape of hri research has many unclear and overlapping terms such as anthropomorphism human likeness sociality animacy mind perception social presence and so forth in this paper we aim to contribute to the ongoing effort of improving the methodological foundations of hri undertaking five steps the first step towards conceptual clarity is to highlight current research practices which we have undertaken here together with step two a suggestion of reporting guidelines in combination with step three a clarification of the conceptual dimensions of anthropomorphism which is the focus of our current and future work we hope to contribute to a solid operationalization and development of standardized assessment tools to assess the phenomenon of anthropomorphism in a sufficiently differentiated fashion that will facilitate future pooling of data across studies and enable convergence between the various lines of research into anthropomorphism in focusing this review on the usage of questionnaires in anthropomorphism research we have highlighted and differentiated the semantic foci of six definitional strategies currently used by anthropomorphism researchers in hri this consolidation and analysis of anthropomorphism assessments and definitional strategies has contributed to the clarification of the theoretical construct thereby providing a foundation for future work to examine how more objective measures can be related to the various definitional strategies items exploring the attribution of capacities for shared intentionality and joint action 1 did x spy out your strategy 29 2 i felt that the robots were talking to each other 58 3 the robotic surface seemed to recognize that you needed a hard surface to write on the robotic surface didnt intend to do anything for you the robotic surface seemed to understand your needs the robotic surface didnt recognize what you needed to do the robotic surface was trying to be welcoming the robotic surface was collaborating with you is the robot pointing teasing flirting welcoming 17 6 please rate the responsiveness of the robot 42 items exploring the human likeness of behavior voice or appearance 1 on a scale of 1 to 5 5 being extremely human how human did you find the robots behavior 10 2 how natural does the voice sound how human does the voice sound how robotic does the voice sound 33 3 please rate the humanlikeness of the handshake 42 please rate the human likeness of the handshake 59 4 how humanlike was the robot 56 5 roomba looked like a living thing nao looked like a living thing 58 items exploring the attribution of cognitive capacities 1 on a scale of 1 to 5 5 being extremely intelligent how intelligent did you find the robot 10 2 the robots have minds of their own 14 3 is the robot getting distracted reflecting 17 4 how intelligent is x did you have the feeling that x used a certain strategy did you spy out x strategy 29 5 how intelligent or unintelligent was the robot during its tasks 56 6 the robotic surface seemed to think when doing something for you the robotic surface had no intelligence at all 7point likert scales 61 7 interview question do you consider the robot surface to be an intelligent agent and why 61 8 how interesteddisinterested in people was the robot 56 9 how organized and committed was the robot 56 items exploring the robots responsibility predictability and agency 1 on a scale of 1 to 5 5 being extremely how responsible did you think the robot came across 10 2 can robi experience agency capabilities † 27 3 i felt that roomba has will i felt that nao has will 58 4 how honest is the voice how trustworthy is the voice 33 5 the robotic surface was acting deliberately the robotic surface was trying to provide a work surface for you the robotic surface was trying to be cooperative the robotic surface was trying to be friendly 7 point likert scales 61 6 this robot is capable of doing things on purpose this robot is capable of planned actions this robot has goals robo deserves blame for its wrongdoings robo is morally responsible likert scale 17 63 items exploring the attribution of a capacity for having or displaying emotions 1 on a scale of 1 to 5 5 being extremely aggressive how intimidating and aggressive did you find the robots behaviour gaze b hand movements c body movement d other 10 2 is the robot aggressing complaining cheering rejecting not not compendex

anthropomorphism represents a central theoretical term in social robotics and human robot interaction hri research however the research into anthropomorphism displays several conceptual problems that translate into methodological shortcomings here we report the results of a scoping review which we conducted in order to explore i how the notion of anthropomorphism is understood in hri and social robotics research and ii which assessment tools are used to assess anthropomorphism three electronic databases were searched two independent reviewers were involved in the screening and data extraction process a total of 57 studies were included in the final review which encompassed 43 different robots and 2947 participants across studies researchers used seven different definitions of anthropomorphism and most commonly assessed the phenomenon by use of amended versions of existing questionnaires n 26 studies alternatively idiosyncratic questionnaires were developed n 17 studies which as a qualitative thematic analysis of the individual questionnaire items revealed addressed nine distinct themes such as attribution of shared intentionality attribution of personality etc we discuss these results relative to common standards of methodological maturity and arrive at the conclusion that the scope and heterogeneity of definitions and assessment tools of anthropomorphism in hri hinders crossstudy comparisons while the lack of validated assessment tools might also affect the quality of results to nurture reflection on these methodological challenges and increase comparability within the field we conclude by offering a set of reporting guidelines for research on anthropomorphism as a first constructive effort to facilitate a coherent theory of anthropomorphismthis study is a contribution to the ongoing effortin hri research and social roboticsto reflect on the methodological foundations of these young multidisciplinary research b malene flensborg damholdt

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introduction the eradication of poverty ensuring health and wellbeing across the lifespan and achieving gender equity by 2030 are central to the sustainable development goals 1 meeting these goals require engaging the key questions what is already known about this topic ▸ rigorous evaluations of microcredit programmes are limited and those that do exist provide mixed evidence on effectiveness for improving economic health and womens empowerment outcomes ▸ productive asset transfer programmes with comprehensive services can increase consumption and income for participating households ▸ limited evidence exists to guide development and evaluation of microcredit or productive asset transfer programmes in conflictaffected settings what are the new findings ▸ an innovative productive asset transfer programme pigs for peace increased economic stability improved subjective health and mental health in conflictaffected villages partnered men and women reported a reduction in perpetration and victimisation in all forms of intimate partner violence although not significantly different from the control group ▸ pfp has the potential to contribute to the achievement of the sustainable development goals through reducing poverty ensuring health and achieving gender equity ▸ pfp demonstrates the importance of partnerships with local expertise to transition from humanitarian granting to household investing for development poorest familiesthose living on 125 daily and often the most marginalised within their communitiesto move from insecure sources of income to more sustainable incomegenerating activities 1 2 3 microcredit and productive assets programmes propose that the borrower or participant operate an incomegenerating activity which had previously been absent or limited by a lack of capital 4 5 6 7 microcredit includes small loans ranging from 50 to 1000 and productive assets transfers are often livestock granted to households or groups serving as collateral for one another 8 9 these financial services have been promoted as supporting business development and increase in household wealth and economic wellbeing of the poor 5 8 10 van rooyen et al 8 conducted a systematic review of diverse microcredit studies implemented in subsaharan africa and found evidence to question the positive impacts on financial outcomes for the poorest members of communities as the investigators noted there were only 15 rigorously evaluated programmes those that included a comparison group available to include in the review those studies judged rigorous enough to review provided mixed impacts including a lack of benefits for the poorest in communities and not increasing household income 8 the review however did suggest that across diverse microcredit programmes health outcomes were improved primarily related to reduction in days missed from work due to sickness the number of episodes of sickness food security and nutrition 8 gaining access to and control over incomegenerating activities may also improve mental health because of the participants perceived ability to meet the needs of the household including educating and feeding children 11 12 13 further the review provided mixed outcomes on womens empowerment 8 two studies conducted in uganda 14 and south africa 15 16 showed evidence that microcredit contributes to womens decisionmaking power in the household and businesses for example the image trial in south africa found a significant improvement in intervention womens ability to negotiate safe sexual practices and a reduction in experiences of intimate partner violence 16 although significant improvements were identified the findings are limited by the inability to separate out the impact of the credit from gender programming on the empowerment outcome although there is little evidence in conflictaffected settings a group savings and loan intervention coupled with gender equity education in cote divoire showed promise in preventing violence in intimate relationships and changing attitudes of men and women that favour or support a husbands use of violence to control or discipline his wife 17 evaluating potential harms such as increased violence in relationships during economic development programmes is critical given the potential of conflict related to shared decisionmaking over spending additional income or perceived threats to husbands authority in the household 4 1618 recent evidence from a multicountry evaluation has advanced the use of productive asset transfer for economic development with the poor 9 the graduation programme was designed by the bangladesh rural advancement committee to provide a comprehensive set of services including a grant of a productive asset to the poorest households in a defined community 9 the idea is to provide a big push over a limited period to reduce extreme poverty the investigators reported positive findings from the grant of a productive asset with comprehensive services increased consumption and income for participating households in all countries 9 in addition to the productive asset grant services include training and support for the asset life skills coaching regular consumption support for a defined period of time access to savings accounts and health information or health services 9 these services plus regular home visits are designed to complement the households in a productive selfemployment activity 9 although the findings are impressive the comprehensive nature of the programme and services is challenging to replicate in a humanitarian and conflictaffected settings such as rural eastern democratic republic of congo the study setting more relevant to the drc context is a zambian livestock transfer programme implemented by heifer international that included training for male and female participants the physical transfer or granting of livestock with training on gender nutrition livestock health and care sustainability accountability resulted in increased cooperation and shared decisionmaking on the use of resources between men and women in participating households 19 drc provides an exemplar of the ways in which prolonged conflict human rights violations and the related negative health economic and social consequences can impact communities 20 21 22 23 24 violence against civilians is used as a deliberate and strategic tactic in war 25 to destroy or expel populations and pillage land and livestock the rural territory targeted for the study reported the loss of land and essential tools for farming resulting in limited agricultural productivity 26 27 the looting or loss of animals has also limited the households ability to pay for health needs school fees and economic shocks or opportunities 26 28 as agricultural production and animal husbandry has decreased in rural eastern drc in the past two decades of conflict 26 29 a cycle of food insecurity 30 poor health and extreme poverty 29 31 has likely been further aggravated by exposure to multiple traumatic events with limited access to quality financial and support services 32 the daily economic health and resource constraints on rural populations in addition to the trauma of violence and forced displacement due to conflict add stress to family and social relationships 33 and may result in conflict and violence of wives by husbands 34 the study authors previously reported on the potential of livestockanimal assets to moderate mental health symptoms for women multiple conflictrelated traumatic events 13 as the household livestockanimal assets increased the impact of conflictrelated traumatic events on symptoms consistent with posttraumatic stress disorder and depression was reduced livestockanimal assets extend beyond its association with household wealth as other measures of wealth did not buffer the effect of conflictrelated traumatic events on mental health symptoms women reported using the funds gained through the livestockanimal asset to pay for school fees purchase land and materials to buildrepair homes thus potentially strengthening self and household perception of productivity and status and advancing wellbeing 13 in 2010 programme dappui aux initiatives economiques a congolese microfinance organisation and the johns hopkins school of nursing joined in collaboration to improve household economic stability health and safety in rural eastern drc 27 the partners adapted their experience in microcredit knowledge of productive asset transfer programmes health and womens empowerment to the drc context and developed pigs for peace pfp is a hybrid programme that integrates microcredit and productive asset transfer principles in rural drc animal husbandry continues to be one of the few opportunities for economic stability as livestock are assets to accumulate to rebuild household wealth and social status 35 pigs are traditional productive assets therefore not intended for regular food consumption but rather serve as a savings account for economic opportunities and crises 26 28 29 the purpose of this study is to rigorously evaluate the effectiveness of pfp on financial and nonfinancial outcomes in a rural conflictaffected setting key questions recommendations for policy methods study design and participants the objective of the study was to evaluate the effectiveness of a hybrid microcreditlivestock asset transfer programme called pfp on economic health and ipv outcomes in 10 villages in the walungu territory in south kivu province the study design was a randomised community trial we hypothesised that at 18 months postbaseline participants in pfp households would have increased economic stability improved subjective health and mental health and less conflict in the household measured by ipv compared with delayed control households the delayed control groups received the pig after the 18month data collection was completed the trial was registered with clinicaltrialsgov nct02008708 in december 2013 a participatory and realistic approach was used to identify villages in the walungu territory for participation in pfp this included feasibility of delivering pfp over a wide geographical area with limited infrastructure commitment to the pfp by traditional chiefs and administrators after detailed discussion with the implementing partner findings from villagelevel assessment including review of administrative data and semistructured interviews with key stakeholders that identified the extreme poverty and vulnerability of residents with limited availability of microcredit andor social programmes and security in the area that allowed for implementation of the intervention pfp livestock microfinance intervention pfp was developed in partnership between paidek a congolese microfinance organisation and jhson 27 pfp uses pigs as productive assets because they are an important source of economic stability and social status with no cultural or religious taboos or genderbased responsibilities related to raising breeding or selling the partners revised the granting of the productive asset a female piglet aged 24 months to a productive asset credit to participating households pfp participants agreed to build a pigpen and compost pit as well as repay the credit by transferring two piglets from the initial litter to other members of the village association after repaying the two piglets the remaining piglets and the original pig is the households to continue to raise breed and sell as they determine however the pfp staff remains available for mentorship and support 13 27 similar to other microcredit and productive asset transfer programmes pfp provided practical skills training to participants on managing nutrition and care of the livestock asset biweekly home visits by trained staff support for association meetings and basic health services by a local veterinarian technician given the longterm humanitarian interventions in eastern drc the local implementing partner paidek was hesitant to provide the consumption support of a regular transfer of food or cash fearing this would imitate the humanitarian approach and limit the participants taking responsibility for the productive asset however after discussion consumption support of 50 kg of palm kernel meal to households was provided when the pig had the initial litter this supported the provision of nutritionrich food during the ∼2 months prior to weaning the piglets thus supporting healthy growth and the ability of participants to repay and transfer pig assets to additional households in the village associations eligibility and randomisation women and men aged 16 years and older were eligible for the project and study if they expressed a commitment to and understanding of pfp were permanent residents of participating villages and were responsible individuals in the household minor participants were eligible if they reported being married widowed parent or headofhousehold the partners decided to avoid women only programming as men are important members of households and their active engagement and support can influence the overall success of the household and programme participation in the study was limited to one eligible adult in the household the eligible man or woman representing the household participated in a public lottery to randomly assign households to the intervention and delayed control group eligible participants placed their name in a container and names were drawn out onebyone by a village child supervised by the study team with the first name drawn assigned to the intervention second to control third to intervention until the planned 66 households were assigned to each condition sixtysix households per village were planned for the study however due to high level of interest in pfp a second delayed control group was formed such that a minimum of 66 households in each village were randomised and the remaining eligible men and women representing households in the village were placed in the second delayed control group data collection procedures baseline data collection took place after translation and back translation of the study questionnaire in french and local languages pilot testing of the questionnaire on tablet computers and randomisation of study participants but prior to training and distribution of the female pig loan to the intervention group the pfp questionnaire was developed to measure our primary outcomes of subjective health ptsd anxiety and depression and secondary outcomes of economic stability and violenceabuse perpetration and victimisation using existing validated research instruments and findings from this teams prior research 13 to address the logistical challenges of working in an extremely lowresource setting the team collected baseline data in two phases of five villages each between 21 may 2012 and 8 november 2012 the followup interviews took place between 7 december 2013 and 4 may 2014 ∼18 months after the first loan pigs was given to a member of the intervention group pig loan distribution was initiated in july 2012 after the first phase of baseline data collection was completed and continued for 7 months as loans were given when participants completed their pigpens the delayed control groups received the pig after the 18 months data collection was completed male and female pfp staff were also trained as research assistants and served as supervisors for 10 male and female congolese research assistants hired and trained for the data collection periods of the study participants reported being comfortable responding to interview questions from male or female research assistants training focused on human participants research ethics interview protocols and safety including providing referrals for health and social support for participants as needed since interviews were conducted when participants would be earning their daily income compensation for their time was provided per local rates ∼us 150 ethics statement the institutional review board of the johns hopkins medical institute approved the study on 18 november 2010 and a committee of respected congolese educators at the universite catholique at bukavu and community members reviewed and approved the study interviews were initiated only after receiving oral voluntary informed consent from the participant oral consent was approved during ethics committee review as the majority of our participants had never attended school so written consent was perceived as a significant challenge and potential barrier to participation inclusion of eligible minors was also approved during the ethics committee review study identification codes and names were recorded during oneonone interviews all data recorded through the tabletbased program were encrypted and uploaded to a passwordprotected and hipaacertified server managed by the study team once uploaded data were automatically erased from the tabletbased program names were centrally removed and stored in a separate file on a passwordprotected study computer study questionnaire demographics and household wealth our questionnaire was developed using validated items from previous studies including the intervention with microfinance for aids and gender equity study team in south africa 16 and the who domestic violence and health study 36 we collected current demographic information from the participant on hisher marital status educational level regular work perceived household wealth in comparison to other households in the village dwelling details and household savings we also asked participants to report on other adults and children living in the household by age and gender economic stability and livestockanimal assets economic stability was measured by the number of cash and noncash loans a participant had in the 12 months prior to baseline interview and the months prior to the followup time point this was dichotomised into none versus one or more loans a total livestockanimal asset score was computed for each participant based on the number and type of animals owned to establish the value of each type of animal the team surveyed nine livestockanimal vendors in five different village markets in the study area and collected the current price to purchase the most commonly owned livestockanimal assets the average cost in us dollars are cows 450 pigs 70 goats 50 poultry 10 rabbits 8 and guinea pigs 1 we computed a total livestock animal asset score for each participants household by multiplying the average market price for the livestock animal by the number of household livestockanimals reported at the baseline and 18month followup interview 13 since these scores were extremely skewed they were recoded into quintiles based on the baseline distribution and the ordinal quintile scores were used in the analysis traumatic events subjective health and mental health the exposure to trauma events section of the questionnaire was adapted from the harvard trauma questionnaire a multipart crossculturally validated instrument that measures traumatic events and ptsd 37 that the team had previously used in the study setting 13 38 exposure to trauma was analysed as a continuous variable a 16item version of section 4 of the htq 39 was used to identify symptoms consistent with ptsd in the past 7 days subjective health was measured with one item rating health from poor to excellent in past 30 days the depression and anxiety components of the hopkins symptom checklist were used for reporting the experience of symptoms that bothered or distressed the respondent during the past 1 month 39 an average symptom score for ptsd depression and anxiety was calculated the htq and hscl have been used widely in conflictaffected and humanitarian emergencies and both have strong psychometric properties for measuring of traumatic events and symptoms consistent with ptsd and depression in conflictaffected settings 40 41 42 in this sample cronbachs α was 086 for anxiety 085 for depression and 089 for ptsd intimate partner violence women were asked about psychological abuse physical andor sexual violence perpetrated by their male partners men were asked about their perpetration of ipv against their female partners the items asked about the partner included humiliating hurting insulting pushing slapping twisting arm or pulling hair punching kicking dragging or beating choking or burning threatening or attacking with a weapon forcing to have sexual intercourse and forcing to perform other sexual acts binary variables were created indicating any experienceperpetration of each of the following types of ipv psychological abuse physical violence and sexual violence statistical power we used data from roberts et al 43 study of the reliability and validity of the sf8 with a conflictaffected population in northern uganda as the basis for our power analyses since we did not have an estimate of the intraclass correlation we varied the icc from 0001 to 0010 for a sample size of 300 per group and assuming no change from baseline to 18 months in the control group and a 10 improvement in the intervention group a α level of 005 the power is 094 089 and 083 for iccs of 0001 0005 and 0010 respectively statistical analysis for the analyses the intervention group was compared with the first delayed control group and the second delayed control group all analyses used a generalised estimating equation approach to control for the clustering of participants within villages the intervention and control groups were compared on baseline variables using a gaussian distribution and identity link function for continuous variables those with and without missing data were compared using the same approach to determine if there were baseline factors related to missingness the analyses were based on intention to treat with all participants included in the main analyses multiple imputation was used to replace missing data based on recommendations of schafer 44 as a sensitivity analyses we compared the results from multiple imputations with a completers only analysis 45 the main gee model was a residualised change regression to examine the difference in continuous variables in the amount of change from baseline to 18 months between the intervention and control groups controlling for baseline scores on the outcome change score on the outcome was the dependent variable predicted from a dummy variable for group and baseline score on the outcome the residualised change model was selected over ancova model because the former accounts for differences in the outcome at baseline and the latter assumes differences between the groups at baseline the analysis accounts for any differences at baseline because the differences may affect the degree of change role of the funding source the funding source did not play a role in the design of the study data collection analysis interpretation or writing of the results the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication results sample description the majority of the 833 household participants were women 25 years or older married had on average 34 children in the home and had never attended school most participants reported living in homes with nondurable walls and roofs very few had savings the vast majority described their household wealth as being the same or worse off than most people in the village the intervention and control groups were not significantly different on any of these variables at baseline the two groups were not significantly different on any of the outcome variables at baseline with the exception of anxiety the control group had significantly higher anxiety than the intervention group lost to 18month followup was not significantly different between the groups 130 of the control group and 162 of the intervention group did not complete the interview men were more likely than women to not complete the 18month interview completers and noncompleters did not differ on age marital status schooling perceived wealth subjective health ptsd ipv livestockanimal assets or having loans at baseline those who were lost to followup had significantly lower anxiety and depression in addition there were no differences between the intervention and control group noncompleters on the baseline characteristics table 2 summarises the baseline and 18month outcomes by group economic status at 18 months postbaseline the participants in pfp reported significantly greater increase in household livestockanimal assets than the control group controlling for assets at baseline participants in pfp were significantly less likely to have one or more loans than control group participants controlling for whether or not they had one or more loans at baseline the same pattern of results was found with completers only participants reported that loans were typically received from family members or friends health centres or small businesses in the village only 1 of participants reported having credit with a traditional microfinance organisation physical and mental health pfp participants had significantly greater improvement in subjective health controlling for their baseline subjective health the intervention group also had greater improvement in symptoms of anxiety and posttraumatic stress but did not differ on change in symptoms of depression the same pattern of results was found with completers only intimate partner violence among men and women who were partnered at baseline and 18 months the groups differed on experiencingperpetrating psychological abuse at 18 months although not statistically significant further partnered women and men in the intervention and delayed control groups reported a decrease in experiencedperpetrated physical and sexual violence the groups did not differ significantly on physical or sexual violence at 18 months importantly the study was powered for the main outcomes using the entire sample therefore the analyses for ipv among those married at baseline and 18 months are underpowered discussion the study findings confirm the hypotheses that participants in pfp households would have increased economic stability and improved subjective health and mental health compared with participants in delayed control households in rural conflictaffected villages in rural drc like rural communities globally animal husbandry continues to be one of the few opportunities for economic stability as livestock are productive assets to accumulate to rebuild household wealth and social status 29 35 livestock is a visible symbol of wealth productivity and social status to the extended family and larger community livestock possession and productivity influences the owners positive perception of self and household wealth 13 28 29 the local implementing partner paidek was essential in identifying the productive asset that would result in improved economic stability and engaging men and women in the programme as cooperation and shared decisionmaking was viewed as critical to success 29 46 47 for example cows and goats were not selected as the productive asset because women cannot sell cows or goats without consent from the husband or male member of the household as these animals are tied to the dowry system as is tradition among the shi people the majority tribe in the study area the future husbands family provides one cow to the future wives family in recent years with the loss of livestock wealth in rural areas goats are often used for the dowry further important in selecting the productive asset is that the vast majority of residents in the target area are either catholic or protestant and porkpork products are produced and regularly consumed thus the pig was the productive asset that represented a genderneutral intervention to bring husbands and wives and other family members together in incomegenerating activities to improve economic stability for the household the findings demonstrated improved subjective health and a reduction in symptoms associated with poor mental health women and men in this area of eastern drc have experienced significant trauma over a prolonged period resulting in symptoms of ptsd depression and anxiety that can negatively impact productivity and family relationships 23 4850 pfp may have reduced these negative mental health symptoms by limiting stress through increased livestockanimals assets and less cash or inkind credit with family friends and others 13 there have been other successful and innovative efforts to address unmet mental health needs through skilled healthcare for example bass et al 48 conducted a study with female sexual violence survivors in eastern drc to examine the effectiveness of an adaptation of group cognitive processing therapy provided by although pfp does not include a womens empowerment component our staff emphasised the importance of communication and shared decisionmaking between husbands and wives in the programme analyses of ipv are based on those who were partnered at baseline and 18 months and do not have adequate statistical power however the pattern of reduction of ipv is clear at 18 months postbaseline fewer participants in the intervention group reported experiencingperpetrating psychological abuse than the control group further reductions in physical and sexual ipv were reported by partnered women and men in the intervention group however the reduction was not significantly different between intervention and control group participants research has suggested that in conflictaffected populations men express a need to recover their authority and role as head of household despite the severe economic and health stress on the family 34 52 with the drc national prevalence of past year frequent physical sexual andor psychological ipv of 439 53 identifying effective approaches to ipv prevention is critical to sustained development womens report of decreased ipv by their husbandpartner was consistent with mens report of reduced use of ipv over the 18month period indepth qualitative interviews were conducted at ∼69 months postbaseline with married partnered male and female pfp participants that reported ipv perpetration or victimisation at baseline the indepth interviews added to our understanding of risk factors associated with ipv in participating households men and women described financial stress including lack of work for men outside the home alcohol use male peer group sanctions use of ipv and social norms that support a husbands role in disciplining his wife as risk factors for husbands use of ipv 54 future pfp programming will include primary prevention of ipv through engaging men and women in changing social norms that sustain gender inequality and reducing the multiple risk factors identified in our work and others that may provide additional reductions in ipv and enhance womens empowerment outcomes pfp prioritised the focus on transitioning from humanitarian granting to household investing for sustainable development the success of pfp provides support for the importance of indigenous expertise in sustainable development programmes to improve economic stability subjective health and mental health and reduce ipv in rural households our implementing partner had the expertise and access to engage traditional and administrative village leaders in productive and culturally appropriate economic activities that supported the participation of men and women 27 partnerships have the benefit of also building local capacity to provide economic and other development initiatives which is a critical step to ending a dependence on humanitarian aid and progress to sustainable development that will advance wealth health and gender equality it is certain that credit and productive asset transfer programmes alone will not solve the multiple challenges facing families in conflictaffected settings however a collaboratively developed and culturally relevant economic development programme that has the benefit of improved health and womens empowerment has potential for advancing sdg this study has limitations the study was conducted in 10 conflictaffected rural villages in 1 province in eastern drc therefore the experiences of the male and female participants are not generalisable to all rural households experiencing conflict participants reported exposure to multiple traumatic events within the past 10 years representing at least two periods of conflict therefore some of the reported traumatic experiences were likely in the recent past and others several years prior to the baseline interview so recall bias is an issue further given the limitations of resources our pfp programme staff was also trained as research assistants and participated in data collection and supervised interns that conducted interviews with participants across the 18 months we also acknowledge the potential for contamination between the groups as the delayed control group households were in the same villages as the intervention households conclusions pfp has important implications for achieving the sdgs with positive findings that intersect areas critical to sustainable developmenteconomic stability improved subjective health and mental health and reduced violence against women pfp has potential for scalability given that it was successful in a challenging rural and conflictaffected setting where residents have extremely limited access to financial institutions or credit programmes health or social services and where social norms that sustain gender inequality are strong handling editor seye abimbola acknowledgements the authors thank all the members of pfp for their participation and willingness to spend their valuable time in responding to our study the authors also thank our congolese team in the field luhazi banywesize alfred backikenge mirindi jean heri banywesize clovis murhula mitima arsène kajabika binkurhorhwa eric mitima ntwali gisele ntakwinja mushengezi gracia kindja sora and nadine mwinja bufole their expertise desire and commitment to rebuilding their communities are what made the study possible contributors ng nap and mmr designed the study participated in development of data collection measures and analysis led data interpretation drafted the manuscript and obtained funding ak managed the data entry data collection for baseline and 18 months and participated in the interpretation of the data and writing of the manuscript jc participated in the design of the study data interpretation and writing of the manuscript the hopkins team collaborated with congolese team on all components of the evaluation but was not directly involved in data collection no other authors have any conflict of interest to declare ethics approval johns hopkins medical institutions provenance and peer review not commissioned externally peer reviewed data sharing statement all data supporting this study and supplementary information are available by contacting the corresponding author open access this is an open access article distributed in accordance with the terms of the creative commons attribution license which permits others to distribute remix adapt and build upon this work for commercial use provided the original work is properly cited see creativecommonsorglicensesby40

randomised controlled trial of a livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a postconflict setting

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introduction heavy alcohol use among collegeage populations defined as drinking an excessive amount of alcohol at one sitting andor drinking to the point of intoxication remains a serious public health concern in addition to the immediate risks of heavy drinking heavy drinking in adolescence and young adulthood has been associated with broader longterm health consequences such as increased risks of alcohol dependence risky sexual behaviors and mental health problems 1 according to the most recent national survey on drug use and health 2 rates of binge drinking are higher among 2125 year olds than among either teenagers or adults aged 26 and older likewise longitudinal research indicates that heavy drinking increases during adolescence and peaks during the mid20s 3 4 5 6 suggesting that the transition from high school to college or noncollege settings is a critical period for development of alcohol misuse crosssectional research has documented higher levels of heavy drinking among college students compared to noncollege youth 7 8 9 10 11 12 for example data from monitoring the future 10 11 12 indicate that although collegebound high school students report lower rates of heavy drinking than their noncollegebound peers they are more likely to exhibit higher levels of heavy drinking during college years however previous work in this area has focused largely on meanlevel comparisons between currentlyenrolled college students and their noncollege counterparts without looking at longitudinal relationships between college education and patterns of heavy drinking only two studies have used nationally representative samples to examine relationships between college education and heavy drinking longitudinally based on a subsample of n7083 participants aged 1324 during the first three waves of the national longitudinal study of adolescent health youth enrolled in 2or 4year colleges reported higher levels of binge drinking and different rates of change in binge drinking than noncollege youth from the late teens to early 20s 13 in contrast the second study based on n7859 participants from the national longitudinal survey of youth found relatively lower levels of heavy drinking from ages 1837 among individuals with at least some college education than individuals who did not go to college with the differences being particularly pronounced between mid20s and early 30s 3 this latter finding suggests that the adverse effects of college attendance on heavy drinking during late adolescence and young adulthood commonly found in research using collegeaged samples may attenuate or even reverse after the mid20s this hypothesis is consistent with crosssectional data collected at age 35 from monitoring the future which showed that levels of substance use including heavy drinking were actually lowest among adults with a college degree compared to both college withdrawers and individuals who did not attend college 14 the longitudinal study based on add health which only measured participants drinking through age 24 could not assess the longterm impact of college education on heavy drinking in later adulthood at the same time the study based on nlsy did not measure drinking behaviors prior to age 18 thus it is possible that the observed group differences were present prior to the college years which may have biased the interpretation of their results longitudinal studies beginning in early adolescence and continuing beyond the college years are needed in order to evaluate the longterm effects of college attendance on heavy drinking throughout adulthood while considering any preexisting differences among groups additionally neither of the two studies examining longitudinal relationships between college education and heavy drinking have considered racialethnic differences in these associations there is evidence that motivations for drinking may differ across race ethnicity for example african americans are more likely to engage in heavy alcohol use in stressful situations such as unemployment or low educational attainment 15 16 17 18 whereas caucasians are more likely to be influenced by peer alcohol use and to drink heavily during celebratory events or holidays 1920 given that drinking behaviors among caucasians may be more strongly influenced by social context the college setting where alcohol is readily available and alcohol use is perceived as normative 18 may be more conducive to excessive alcohol use for caucasians than for african americans several crosssectional studies have found that caucasian college students report higher levels of heavy drinking than their noncollegeeducated counterparts but college attendance is inversely related to or not associated with heavy drinking among african american youth 172021 however as these studies were crosssectional it is unclear whether the observed racialethnic differences were present prior to young adulthood andor whether differences persisted beyond the college years using a nationally representative sample the current study compares longitudinal relationships between college education and patterns of heavy drinking from early adolescence to adulthood for caucasians and african americans gender is included as a control variable given observed differences in levels of and changes in alcohol use and heavy drinking across males and females 5622 parental education is also included as a covariate given its association with both alcohol use 2324 and academic attainment 25 26 27 we compare patterns of heavy drinking among four different groups noncollege youth collegewithdrawers 2yearcollege graduates and 4year college graduates given prior evidence supporting differences in heavy drinking between these groups 1321 based on findings from previous crosssectional research we hypothesize that college education will be more strongly associated with both changes in and levels of heavy drinking for caucasians than for african americans we did not develop hypotheses about the specific differences across the four college education groups in trajectories of heavy drinking as there is a lack of theoretical and empirical work considering these betweengroup differences separately for caucasians and african americans methods sample data are from waves i through iv of the national longitudinal study of adolescent health 28 add health is a populationbased nationally representative sample of adolescents followed longitudinally add health includes youth aged 1121 1222 1828 and 2434 at waves i ii iii and iv respectively current analyses focus on comparisons between the two largest groups nonhispanic caucasians and nonhispanic african americans the present sample is restricted to participants with data on heavy drinking in at least one of the four waves and who reported college education status in wave iv missing data was processed with listwise deletion resulting in a sample of n11383 participants in addition we excluded participants whose reports of educational status were inconsistent and participants who were attending school at wave iv but had not yet achieved any type of degree as their college completion status remained unknown wave i data for 305 participants younger than age 13 and wave iv data for 179 participants older than age 31 were also excluded because sample sizes at these ages were too small to be representative of each racial and college status group the final sample size for the current study is n9988 measures ageparticipants ages were calculated by subtracting their birth date from the interview date at each of the four waves of data collection gendergender was coded as 1male and 0female the sample consists of n4731 males and n5257 females parental educationadolescents reported the highest level of education achieved by their residential mother and residential father during wave i responses ranged from 0never went to school to 9professional training beyond a fouryear college or university parental education was averaged across both mothers and fathers for youth who lived with two parents raceselfreported race obtained in wave i was coded as 0nonhispanic caucasian and 1nonhispanic african american college education statusat wave iv participants were asked to indicate the highest grade or year of regular school they had completed and the most recent degree they had received based on their responses participants were classified into four groups 1 a noncollege group 2 a collegewithdrawer group 3 a 2yearcollege group and 4 a 4yearcollege group heavy drinkingtwo items at each wave assessed heavy drinking in the past year a how many days participants drank ≥5 drinks in a row and b how many days participants had gotten drunk or very high on alcohol responses for both items ranged from 0never to 6everyday or almost everyday items were strongly correlated and were averaged to create a heavy drinking score the heavy drinking score was positively skewed and was log transformed for analyses analytic plan growth curve modeling was used to examine trajectories of heavy drinking across age 29 four models were fitted using multilevel hierarchical regression analyses in spss an unconditional means model estimating the withinindividual and betweenindividual variance of heavy drinking an unconditional growth model testing both the linear and quadratic change in heavy drinking a conditional model examining relationships between control variables race and college education with initial levels and rates of change of heavy drinking and an interaction model testing racial differences in relationships between college education with initial levels and rates of change of heavy drinking for initial analyses age was centered at 13 to explore relationships between college education and initial levels of heavy drinking and dummy variables for college education were created using noncollege participants as the reference group analyses were rerun with age centered at each age point from ages 1431 to test for differences in levels of heavy drinking across the entire age range similarly to thoroughly test relationships between college education and heavy drinking differences in rates of change and levels of heavy drinking among the three college attendant groups were further tested in separate followup analyses using the collegewithdrawer and the 2yearcollege group as the comparison group missing data in heavy drinking were handled utilizing maximum likelihood the fit of each model was calculated using a 2 loglikelihood comparisons across models were based on the differences in 2ll between models results analysis was conducted to compare african american and caucasian participants included in and excluded from the final sample exclusion rates were higher among african americans than caucasians differences were also found in gender age and parental education males were slightly more likely to be excluded than females excluded participants were older and reported lower levels of parental education at wave i although these latter differences were quite small no significant differences were found in wave i levels of heavy drinking between included and excluded youth we were unable to compare college education or rates of heavy drinking at waves iiiv as most of the excluded participants had missing data on these measures table 1 shows demographic characteristics of participants in each college education group african americans were more likely to be in the noncollege and collegewithdrawer groups and were less likely to have completed 2year or 4year degrees than caucasians although differences were relatively modest males were overrepresented in the noncollege group and females overrepresented in the 4yearcollege group parental education was lowest among the noncollege group and highest among the 4yearcollege group with the two other groups falling inbetween results from the hierarchical growth curve models are shown in table 2 based on the intraclass correlations 297 of the variance of heavy drinking existed between individuals while the remaining variance was due to withinperson factors including age the unconditional growth curve model had a significantly better fit than the baseline model fixed effects for the linear and quadratic function of age were both significant specifically levels of heavy drinking increased from age 13 reached a stationary point between ages 2425 and then declined thereafter results from model 3 revealed that males exhibited significantly lower initial levels of heavy drinking but had significantly faster rates of linear and quadratic change than females greater parental education was associated with lower initial levels and higher rates of linear and quadratic change of heavy drinking initial levels of heavy drinking did not differ significantly between african americans and caucasians however african americans reported slower rates of linear and quadratic change results from model 3 also indicated significant relationships between college education status with both initial levels and rates of change of heavy drinking however findings from model 4 which had a significantly better fit than model 3 suggested racial differences in these relationships therefore patterns of heavy drinking of the four college education groups are shown separately by race in figure 1 college education was significantly associated with rates of change of heavy drinking for caucasians but not for african americans all of the differences in rates of change of heavy drinking among college education groups were significant for caucasians except for comparisons between the collegewithdrawer and the 2yearcollege groups among caucasians noncollege participants showed the slowest rate of increase from age 13 to mid20s and the slowest rate of decline from mid20s to age 31 whereas heavy drinking both increased at the fastest rate from age 13 to mid20s and declined most rapidly thereafter among the 4yearcolleage group rates of change of heavy drinking for collegewithdrawers and 2yearcollege graduates fell inbetween those of the other two groups in contrast to the patterns observed among caucasians none of the betweengroup comparisons in rates of change of heavy drinking were significant for african americans analyses centering age at each age point from ages 1331 revealed racial differences in relationships between college education and levels of heavy drinking for caucasians significant betweengroup differences in levels of heavy drinking were evidenced across virtually the entire developmental period the noncollege and the 4yearcollege groups generally exhibited the highest and the lowest levels of heavy drinking from ages 1318 respectively with the other two groups falling inbetween whereas an inverse pattern was observed from ages 2029 only the differences between the noncollege and the 4yearcollege groups remained significant at age 30 no significant betweengroup differences were found at age 31 among african americans noncollege youth exhibited the highest levels of heavy drinking from ages 1319 although this is similar to patterns observed in caucasians differences were not as marked and only the comparisons between the 4yearcollege group with the noncollege and collegewithdrawer groups were significant from ages 2025 there were no significant betweengroup differences in levels of heavy drinking finally african american college withdrawers consistently exhibited significantly higher levels of heavy drinking than their noncollege and 4yearcollege counterparts after age 25 and these differences persisted through ages 3031 discussion the present study compared longitudinal relationships between college education and patterns of heavy drinking for caucasians and african americans drawn from a nationallyrepresentative population our study extends previous research in this sample by examining the longterm associations between college education and patterns of heavy drinking during the late 20s and early 30s in addition this is the first study to examine and demonstrate racial differences in longitudinal relationships between college education and patterns of heavy drinking similar to patterns reported in crosssectional studies examining racial differences in relationships between college education and heavy drinking 172021 we found that college education was more strongly associated with patterns of heavy drinking for caucasians compared to african americans among caucasians differences between college education groups in both changes in and levels of heavy drinking were significant in comparison to the noncollege group heavy drinking increased more rapidly for college attendants from early adolescence to mid20s especially for 4yearcollege graduates furthermore levels of heavy drinking for 4yearcollege graduates surpassed those of their noncollege agemates from ages 2025 these patterns observed among caucasians are generally consistent with findings from prior crosssectional studies of collegeaged samples which suggest a positive association between college attendance and heavy alcohol use 91112 30 31 32 33 34 however our longitudinal study explicitly demonstrates that differences in levels of heavy drinking between college attendants and noncollege youth diminish during the late 20s and disappear entirely by ages 3031 for caucasians consistent with the hypothesis that social context plays an important role in the etiology of drinking behaviors among caucasians 1920 one explanation for this age trend is that caucasian college attendants may desist from heavy drinking during postcollege adulthood as a result of their transition to social settings that discourage excessive alcohol use 14 an alternative but related explanation is that protective factors associated with graduating from college such as higher income and more stable employment 35 may account for the faster decrease in levels of heavy drinking among college graduates after the college years 3637 future research could determine whether life transition events andor protective factors explain the marked decrease in heavy drinking during the late 20s and early 30s observed among caucasian college attendants although the patterns observed among caucasians are largely consistent with prior research a novel finding from the present study is the different patterns of longitudinal relationships between college education and heavy drinking among african americans most notably in contrast to caucasians college education was not related to patterns of change in heavy drinking over time for african americans moreover no differences in levels of heavy drinking were found between any of the four groups from ages 2025 our results therefore indicate that among african americans going to college does not confer the same risk of increasing rates of drinking behaviors even in the short term observed in caucasians the lack of differences between college and noncollege african americans from ages 2025 reinforces the hypothesis that social factors play a less important role in shaping drinking behaviors among minority individuals 1920 we also found racial differences in relationships between college withdrawal and levels of heavy drinking in adulthood among caucasians levels of heavy drinking were elevated among college withdrawers compared with noncollege participants from ages 2029 but were still lower than the 4yearcollege group differences between college withdrawers and the other groups among caucasians also disappeared entirely by ages 3031 in contrast among african americans higher levels of heavy drinking observed among collegewithdrawers did not become significant until age 26 and the elevated levels of heavy drinking among college withdrawers persisted through the early 30s suggesting a delayed and potentially longerlasting impact of college withdrawal among african americans levels of heavy drinking among college withdrawers were further higher compared to both noncollege participants and participants with 4yearcollege degrees among african americans suggesting that this subgroup is at greatest risk for the development of problematic alcohol use we note however that the present study cannot determine the causality of college education completion status and drinking behaviors heavy drinking may have resulted in poor school performance which may in turn have led to college withdrawal 38 studies obtaining repeated measures of heavy drinking and academic performance especially among african american college students can further clarify causal relationships between these processes limitations our results should be interpreted in the context of several limitations first our measures of heavy drinking are imperfect frequencies of heavy drinking over the past 12 months were assessed using a likertbased frequency scale rather than actual number of days this approach may give unnecessary weights to extreme drinking episodes andor more recent drinking episodes in addition we did not use genderspecific cutoff points to characterize heavy drinking although we acknowledge these limitations similar measures of heavy drinking have been used in previous longitudinal studies examining relationships between college education and patterns of heavy drinking 313 and in crosssectional studies examining racial differences in these relationships 172021 thus the use of these measures in the current study enables a more direct comparison with prior research moreover gender differences in both rates of change and levels of heavy drinking were adjusted in our analyses so that gender differences in cutoffs of heavy drinking are unlikely to have biased the studys primary results relatedly as the current study is focused on patterns of heavy drinking our results may not generalize to other measures of alcohol use such as typical quantity or frequency a third limitation is that attrition rates were higher among males and african americans and we were unable to compare educational levels or rates of heavy drinking at waves iiiv between included and excluded participants therefore results of the present study need replication in other samples before any firm conclusions could be drawn finally future studies are needed to explicitly test if a wide range of known correlates of drinking behaviors 39 account for racial differences in relationships between college education and heavy drinking reported in the present study despite these limitations findings from the present study are informative as they are the first to demonstrate racial differences in the longitudinal relationships between college education and patterns of heavy drinking implications and contribution this study is the first to examine racial differences in longitudinal relationships between college education and heavy drinking findings suggest that in later adulthood college attendance may not have longterm risks on heavy drinking for caucasians whereas african american college withdrawers may be particularly vulnerable to developing alcohol use problems racial differences in effects of college education on developmental trajectories of heavy drinking note betweengroup differences for caucasians rates of changes all betweengroup differences in rates of change were significant except for differences between the collegewithdrawer and the 2yearcollege groups levels of heavy drinking in adolescence the 4yearcollege group had significantly lower levels of heavy drinking than the collegewithdrawer and noncollege groups at ages 1318 the noncollege group had significantly higher levels of heavy drinking than the 2yearcollege group at ages 1317 and significantly higher levels of heavy drinking than the collegewithdrawer group at ages 1316 the 2yearcollege group had significantly higher levels of heavy drinking than the 4yearcollege group at ages 1316 differences between the collegewithdrawer and 2yearcollege group were not significant at ages 1318 none of the betweengroup differences were significant at age 19 levels of heavy drinking in adulthood the 4yearcollege group had significant higher levels of heavy drinking than the noncollege and 2yearcollege groups at ages 2029 and significantly higher levels of heavy drinking than the collegewithdrawer group at ages 2229 the collegewithdrawer group had significantly higher levels of drinking than the noncollege group at ages 2029 the 2yearcollege group did not differ significantly from either the collegewithdrawer group or the noncollege group at ages 2029 finally at age 30 only the comparison between the 4yearcollege and noncollege groups was significant and none of the betweengroup comparisons were significant at age 31 betweengroup differences for african americans rates of change none of the betweengroup differences in rates of change of heavy drinking were significant levels of heavy drinking in adolescence the 4yearcollege group had significantly lower levels of heavy drinking than the noncollege group at ages 1319 and significantly lower levels of heavy drinking than the collegewithdrawer group at ages 1518 none of the other group comparisons were significant at ages 1319 levels of heavy drinking in adulthood no significant betweengroup differences were found at ages 2025 the collegewithdrawer group had significantly higher levels of drinking than the 4yearcollege and the noncollege groups at ages 2631 none of the other betweengroup comparisons were significant at ages 2631

purposethe current study compared longitudinal relationships between college education and patterns of heavy drinking from early adolescence to adulthood for caucasians and african americans methodsdata were collected from n9988 nonhispanic caucasian and african american participants from all four waves of the national longitudinal study of adolescent health growth curve modeling tested differences in rates of change and levels of heavy drinking from ages 1331 among noncollege youth college withdrawers 2yearcollege graduates and 4yearcollege graduates and compared these differences for caucasians and african americans resultsthere were significant racial differences in relationships between college education with both changes in and levels of heavy drinking rates of change of heavy drinking differed significantly across the college education groups examined for caucasians but not for african americans in addition caucasians who graduated from 4year colleges showed the highest levels of heavy drinking after age 20 although differences between the four groups diminished by the early 30s in contrast for african americans graduates from 2or 4year colleges did not show higher levels of heavy drinking from ages 2031 than the noncollege group instead african american participants who withdrew from college without an associates bachelors or professional degree consistently exhibited the highest levels of heavy drinking from ages 2631 conclusionsthe relationship between college education and increased levels of heavy drinking in young adulthood is significant for caucasians but not african americans conversely african americans are likely to be more adversely affected than caucasians by college withdrawal

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introduction patron comes from the latin word patronas meaning nobility while client comes from the word client which means follower in spanish the term patron means someone who has great power status authority and influence the patronclient relationship was first described in anthropological research as a way to define interpersonal relationships in small groups and communities in which indviduals are not equal in terms of status power and income thus placing the client in a lower position and the patron in the higher this type of relationship tends to occur spontaneously in contexts where wealth power or important commodities are distributed unequally and can potentially benefit all parties involved patronage relationships predated the romans in many parts of the world weaker and more vulnerable parties seeking protection regularly entered into formal or ad hoc relationships with more powerful parties desirous of the services the weaker party could provide shadle added how male and female cilents in southwest kenya assited in different ways male clients strengthened a homesteads defenses and female clients increased its capacity for reproduction these africans sought for new patrons a function missionaries cheerfully filled as all clients assisted with agriculture the surplus of which attracted and sustained yet more clients in returns missionaries provided food and shelter in south kavirondo one priest violently attacked men who tried to remove their sister from the mission station and after some masses priests killed bulls for feasts the priests required labor and allegiance in exchange converts mowed the lawn built houses and worked in the fields of the missions many studies have documented patronage practices in various parts of the world including latin america the carribean and pacific europe the persian gulf asia and indonesia such institutions are widespread in indonesia and can be found in east java yogyakarta sulawesi kalimantan just as patronage relationships are not restricted to any particular geographic region neither are they restricted to any particular social economic political or cultural sector pelras documented patronage relationships in the traditional life of the bugis and makassar other studies have revealed how patronage relationships govern fisheries in south sulawesi and berau kalimantan a number of scholars have published on the role of patronage relationships in the politics of indonesia and other countries political patronage often becomes entangled with economic patronage it is not uncommon for powerful patrons to run for office in political democracies and rely on their clients to whip votes spread propaganda and generally tilt the political landscape in their favor in other cases the client may run for office with support from the patron and repay this support in cash or by means of government projects and programs that benefit the patron in cultural and historical context hashmi argued a prevalent belief that one of the factors contributing to sanskrits downfall during the rule of muslim rulers or sultans was the languages lack of attention there have been several academic articles written both in favor of and against this concept over time similar to this sultan mahmood shah i of gujarat is the subject of numerous contradicting claims in historical texts several facts that contradict many of the claims made about mahmud shah i have been brought up in modern scholarship he was a mentor of sanskrit as well as a lover of the language and literature and in his court a sanskrit poet had the status of malekush this is just one of the characteristics that have been highlighted arguably patronage relationships inevitably form in the context of complex societies such institutions may even be prerequisites for certain cultural activities like the performance arts lengger and ronggeng which are native to banyumas the southeastern part of central java indonesia to arise and persist in indonesia patronage relationships govern many other sectors of society not all of which have been well documented to date for example few studies have addressed the role that patronage plays in indonesias cultural institutions to address this deficit this study investigates representations of patronage in the novel ronggeng dukuh paruk by ahmad tohari rendered in english by rene t lysslof as the dancer set in banyumas a small regency in southeastern central java the dancer synthesizes fictional elements with the collective memory of the community and documents local beliefs and practices surrounding a javanese dance tradition the novel therefore doubles as an ethnographic document through an investigation of this text this study elucidates three central points 1 how patronclient relationships are established and maintained in the ronggeng dance tradition 2 the functional and cultural significance of patronage in this tradition and 3 the nature of the services rendered by the dancer as client to the ronggeng dukun as patron review of the literature patronclient relation according to scott for patronclient relationships to arise and persist several elements must be present first both parties must agree that whatever they exchange has value whether it be goods services protection or something else second the gift from the patron must make the client feel obliged to act on the patrons behalf either by inspiring reciprocity through positive feeling or by intimidating the client into submitting to the patrons will lest the gift be taken away patronage relationships also need to be supported by societal norms so that clients can negotiate effectively with their prospective patrons allowing either party and not just the more powerful patron to withdraw from the relationship if it no longer meets their needs patronages fundamental component is trust in different ways it integrates with and transcends other selection criteria due to the asymmetrical power relationships between patron and appointee appointments typically end when there is a breakdown in trust hence it can be concluded that patronage relationships will spontaneously emerge in circumstances where power and commodities are unequally distributed where facetoface meetings between patrons and clients are possible and where societal norms enable clients to negotiate effectively and leave or alter the terms of the relationship when necessary according to scott there are two types of patronage relationships traditional and modern traditional patronage relationships tend to be particular spread and informal whereas their modern counterparts tend to be universal and contractual in nature in traditional patronage relationships patterns of exchange tend to be highly variable reflecting the particular array of resources at each partys disposal as well as their individual personalities desires and needs in traditional patronage relationships patrons and clients negotiate their relationships ad hoc without any explicit working agreement in traditional patronage relationships friendship or kinship terms are often invoked to lend structure to otherwise informal social dynamics patronage relationships in indonesia for instance are commonly referred to as fatherson relationships even in the absence of formal contracts both parties have distinct roles and relationships that they must meet in order to further their mutual interests and the relationship continues as long as both fulfill their obligations the father must meet the needs of the child whereas the child must be willing to carry out the orders of the father usually performing manual tasks or offering useful services these relationships may deteriorate for a variety of reasons if a patron can no longer ensure the clients social economic or physical security then the client may reconsider the value of the relationship with the patron the same thing can happen if the client manages to accumulate sufficient resources to achieve socioeconomic independence which means he no longer dependent on patrons according to scott patronage relationships can be divided into five basic categories depending on what types of goods are services are exchanged these categories are as follows a basic subsistence livelihood in agrarian societies patrons may give clients longterm guarantees of work land seeds or equipment for farming marketing services technical advice and others b subsistence crisis guarantees patrons may support their clients when clients suffer illness misfortune or injury for instance if a clients crops fail or if the client is unable to harvest those same crops because of infirmity the patron may provide them with food to live and additional capital to plant a new crop the following year the patron thus serves as the clients safety net in times of trouble c protection as was common throughout feudal europe patrons may protect clients from personal harm or public harm d brokers and influencers in addition to protecting clients from harm patrons may use their power and influence to attract gifts on behalf of his client e collective patron service as a group patrons may also perform their functions collectively they may offer donations or subsidize aid to one anothers clients donate land to collectives build public facilities such as roads schools community buildings host visiting officials sponsor public festivals and so on the flow of goods and services from clients to patrons on the other hand generally takes the form of manual labor usually the services provided by clients are basic work services such as agricultural labor provision of water and firewood to the patrons households private domestic services and participation in local factions loyal to the patron one critical factor in determining the longterm stability of the patronage relationship according to scott is whether it is collaborative or exploitative in nature to evaluate this one must compare the value of the services rendered by clients with those provided by the patrons the greater the value of the patrons contribution compared to the clients the more collaborative the patronclient bond another crucial factor is whether these exchange rates adhere to the established local norms as long as exchange rates remain stable and patrons continue to provide subsistence and protection patronage relationships tend to persist however even minor fluctuations in the standard exchange rate can trigger resistance if they reduce the farmers profits finally scott asserts that the basic purpose of the patronclient contract is to establish and maintain widespread social stability subsistence and security sometimes these distributed benefits come at the concentrated cost of exploitative patronclient relationships but under other conditions relationahips between patrons and clients can verge on truly equitable when there is public land available for planting and when farmers can rely on relatives for protection or on moneylenders for loans their dependence on patrons is dramatically reduced and this in turn enables them to negotiate more favorable arrangements and play an active role in shaping the patronage relationships of which they are part methodolgy this study takes a descriptive and qualitative approach its goal is to describe the existing reality using established concepts and categories qualitative methods are used commonly in the social sciences and humanities to analyze various issues such as democracy race gender class globalization and freedom this method allows researchers to collect information about a phenomenon in a comprehensive manner in this case the data are narrative summaries expositional quotes and excerpted dialogue from the novel ronggeng dukuh paruk for the sake of practicality all quotes have been taken from the english version the dancer translated by rene ta lysloff the selected sections portray the patronclient relationship between srintil female protagonist and the shaman her patron these selections have been analyzed using the patronclient theory as a primary framework supported by findings from other relevant studies results and discussion this study analyzes three central elements of the patronclient relationship in ronggeng culture 1 how patronclient relationships are established and maintained 2 the functional and cultural significance of patronage in this tradition and 3 the nature of the services rendered by the dancer as client to the ronggeng dukun as patron these issues are explored based on the literary data derived from analysis of td some scholars see this novel as an etnograpic work that accurately depicts its setting including the cultural historical and political events in the narration the making of the patronclient relationship in the ronggeng tradition patronage functions rather differently than it do in many other sectors of society in this tradition only a dukun or shaman can serve as a patron likewise only a ronggeng dancer can become a client the instrumentalists for example cannot become clients their relationships with the dukun are purely transactational as they are paid for each performance in the novel kartareja is the only shaman in the hamlet and therefore the only eligible patron to become a ronggeng dancer it is not enough for a girl to simply be trained by the shaman a ronggeng candidate must be chosen by an indang spirit who inhabits her and her status is revealed to the community when she manifests certain skills without any teaching from others only one girl can become a ronggeng in a generation for the spirit will not inhabit another girl until the current ronggeng dies nor will the spirit inhabit a new girl immediately the shaman might have to wait for years for the new reincarnation srintil the protagonist in td is chosen by the indang spirit after eleven years since the previous ronggeng died it was eleven years since the last ronggeng dancer of paruk had died the ronggeng dancer plays a very important role in this culture without her there can be no performances and if too much time passes between incarnations the cultural tradition may even die thus as a client the dancer is not inferior to the shaman her patron their relationship is founded on mutualism each needs the other and each benefit from the other the arrival of the indang is considered a blessing for everyone the girl the shaman and the community at large the communal significance of this event is revealed by the following passage the bottom line is that paruk village will once again have a ronggeng dancer kartareja sighed those of us in ths hamlet who are elderly dont want to die before seeing paruk return to what it once was… if i dont preserve the ronggeng tradition of this hamlet paruk village without a ronggeng dancer isnt paruk village srintil my own granddaughter will bring back the greatness of this village said sakarya to himself the patronage relationship in the ronggeng tradition is primarily spiritual cultural and social in its orientation as opposed to economic or political once identified a ronggeng dancer receives support from all the community members the shaman becomes responsible for the life of the ronggeng candidate and her development into a fully fledged ronggeng dancer the following passage illustrates this transfer of responsibility from the ronggeng candidates birth family to the dukun thereafter they decided that on an auspicious day srintil would be presented by her grandfather to kartareja the custom in the village for handling a potential ronggeng dancer was for the family of the candidate to give her over to the dukun to become his adopted child sakarya srintils grandfather is obligated to hand over srintil to the ronggeng shaman kartareja and he does so readily sacrificing his relationship with his granddaughter in order to perpetuate the ronggeng culture in this way legitimized by the consent of the ronggeng candidates family and her community the patronage relationship is formed patronage in traditional dance culture in accord with scotts schema three categories of patronage are depicted in the dancer 1 fulfillment of basic neccesities 2 protection and 3 crisis insurance in this cultural context basic necessities includes not only food and shelter but also beautification socialization and rigorous dance training fulfillment of basic necessities the first step in forming the patronage relationahip in the ronggeng tradition is for the candidate to be given by her birth family to the dukun this step is taken after both sakarya and kartareja see srintil dance both conclude that srintil has been possessed by the ronggeng spirit and agree that she must be handed over to kartareja as illustrated below as the ronggeng dukun kartaraeja becomes responsible for providing all her basic needs thereafter they decided that on an auspicious day srintil would be presented by her grandfather to kartareja the custom in the village for handling a potential ronggeng dancer was for the family of the candidate to give her over to the dukun to become his adopted child in other sectors patrons are usually only responsible for providing their clients with basic subsistence but in the ronggeng tradition necessities include luxury items such as jewelry and elaborate clothes ronggeng candidates are expected to maintain a higher standard of living than the other people in the hamlet and anything less amounts to a failure on the part of the patron in accordance with this expectation srintil is served meals of rice and vegetables chicken meats and fruits at that time even rice was considered a luxury item for most people ate only tapioca gruel and corn rice the food was not only provided by the shaman family but also by other members of the community who collectively subsidized srintils ronggeng candidacy with physical capital ie donations that promoted her physical and spiritual beauty in the space of a month writes tohari srintil had visibly changed beauty as a basic necessity the beauty of a ronggeng dancer has two aspects physical and spiritual physical beauty is achieved by applying traditional herbs to enhance her appearance turmeric powder gives her skin a yellow tinge and betel reddens her lips her eyebrows are blackened with root resin this procedure is performed every time as she performs a traditional dance the following passage illustrates her transformation her skin glowed from the application of a mixture of powder and turmeric water the wife of the dukun had ordered srintil to chew betel and her young lips had turned bright red the fine hairs behnd her cheeks near her ears became more apparent after srintil was powdered her thin eyebrows were thickened with a mixture of root and papaya resin making her look like a doll srintils teeth are also filled and covered with a golden layer all of these cosmetics are provided by her patron i saw that her teeth had been filed when srintil smiled a soft ray of light reflected from one of her front teeth that had been capped with gold besides beautifies srintils body the patron is also responsible for training srintil as a dancer though her skill is divinely gifted to her a dancer still needs further guide from her patron the shaman as true ronggeng dancer srintils dancing should provoke any adult male who saw her vague feelings of lust and desire always engendered by true ronggeng dancers were aroused in her young audience by srintil while she danced the sweep of her neck the glance of her eyes even the way she swayed her shoulders would have mesmerized any adult male that saw her in addition to physical beautification supernatural procedures are also performed to enhance the ronggeng dancers spiritual beauty these include black magic love charms talismans as indicated in the following passage these procedures are believed to make her much more beautiful to make her even more desirable mrs kartareja had also inserted several gold talismans under srintils skin it is a love charm used as a talisman by ronggeng dancers in the past for javanese culture inserting gold talisman is a common practice to gain power in srintil case the power means charms to mesmerized adult male as suggested by anderson regarding power in javanese culture power is physical this is the fundamental tenet of javanese culture political analysis power exists regardless of whether it is achievable users it is an existential reality rather than a theoretical premise power is that elusive enigmatic and heavenly energy that creates the universes life universe is expressed in stones trees clouds and fire yet it is fundamental traditional javanese thought does not make clear distinctions organic and inorganic matter because everything is sustained by the same unobservable force this idea that the whole due to the cosmos being infused with a formless perpetually creating force the fundamental connection between the animism of javanese communities and the sophisticated pantheism found in urban areas according to andersons theory the ronggeng shamans actions make logic and are thought to be able to enhance the ronggeng dancers beauty and charisma ritual preparations in addition to beautification and training the ronggeng candidate must complete a series of rituals in order to become a ronggeng dancer these include dance perfomances beginning with her first initiation an introduction to the ancestors and finally the bukak klambu during which the dancers virginity is auctioned off to the highest bidder the shaman as patron is responsible for ensuring that all these rituals are fulfilled all especially the bukak klambu require significant financial expenditures as depicted in the following passage kartareja himself was required to spend money for the event he sold three goats at the market and with the money bought a new bed for her complete with mattress pillow and mosquito net in this bed srintil would be deflowered by the man who won the contest today the total expenses for this ritual alone would come to approximately idr 10 million however the dukun does not hesitate to sell his property to raise the necessary funds not just to fulfill his obligation to the community but also to make srintil eligible to serve as a ronggeng dancer and rake in profits in the future an arrangement from which he will benefit directly the services of the dancer to the patron the services rendered to the shaman by the ronggeng dancer are very different than those rendered by clients in other types of patronage relationships she does not serve the shaman directly by performing manual labor instead she gives public dance performances and works as a prostitute and he collects the proceeds there are three distinct channels through which the dancer earns money on behalf of her patron the bukak klambu ritual public dances performances and other community services the shaman for his part serves alternatingly as an agent manager and pimp for his client depending on which service she is rendering at any given time this combined with his having sponsored her training and induction gives the shaman a great deal of power and control over the dancers daily life as well as her financial resources this dynamic is made explicit in the following dialogue yeah a ronggeng trainer usually wants to take care of every aspect of her charges life often even wishing to control her possessions ive heard that i know that a ronggeng is often considered prime livestock by her guardian think of all the times people hold rituals or during the harvest season a ronggeng has to perform every night during the day she has to service the men and the person handling her affairs especially those involving money is the dukun you cant help but feel sorry for srintil can you on the other hand mr and mrs kartareja have become fairly wealthy out of it havent they in a patronclient relationship the client is required to repay the patron for all the services they have provided srintil though provides more as a client than kartareja does as a patron it appears as though the dukun ronggeng have taken advantage of srintil and exploit her in the name of ronggeng culture srintil however asserts that what kartareja did was truly her responsibility to repay the favor to the ronggeng shaman who had made her a wellknown ronggeng and that in fact that was the duty that a ronggeng dancer was required to carry out the virgnity auction the bukak klambu or opening of the mosquito net is a type of competition open to all men who can pay amount of money determined by the dancers trainer this ritual also functions as a rite of passage inaugurating the ronggeng candidate as a fullfledged ronggeng dancer the bukak klambu ritual synthesizes all three elements of her roledancer prostitute and public service providerin a single event which only further demonstrates her patrons power over her body and her life the bukak klambu formalizes the shamans right to exploit and profit off of srintils labor as a client srinitl has few choices kertareja has already invested his resources in her creating a sense of obligation this obligation is further enforced by social attitudes and tradition the entire community expects her to provide the public services her patron has sponsored and produce good returns on investment for him this communal attitude is made explicit in the following passage i have decided that the time will be next satuday said kartareja addressing a large group of men at the market and you want a gold piece thats right i believe its a fair price answered kartareja the man who asked the question gasped from a capitalist economic perspective the bukak klambu is not just an auction but also an investors meeting whereby the shaman attempts to raise present and future capital the higher the price paid for srintils virginity the greater her prestige and by extension the shamans and the whole dukuh paruk communities this will also enable kertareja to charge more for her services in the future after the bukak klambu the ronggeng dancer transforms into a reliable source of capital for the shaman and his family the price of dance performances the first channel by which the ronggeng dancer generates income for her patron is through public dance performances the ronggeng shaman organizes these performances at the request of community members and takes the biggest cut of the profit on the other hand mr and mrs kartareja as the shamanistic practitioners of ronggeng knew all the details related to the world of ronggeng knew all the details related to the world of ronggeng and used this knowledge and their status as the basis of their livelihood they took percentage of srintil performance fee that was often more than that which srintil herself received their cut was even larger when they acted as procurers it is common in java for the profits from public performances to go to the organizers but generally the organizers are also the performers this is the case for example in kuda lumping or puppet shows ronggeng performances are distinct insofar as the stage belongs to the dancer not the shaman during the performance itself but ultimate control of the profits lies with the patron the wives of dukuh paruk even actively encourage their husbands to tip more so they can have sex with the ronggeng dancer and that this act bestows prestige on the entire household the ronggengs choice will be the man that gives her the most money and in this regard my husband is unbeatable well dont get too cocky i could sell a goat so that my husband has enough money i still believe that my husband will be the man who first kisses srintil on top of the cost of entry additional revenue is made in the form of tips given by male audience members of saweran who join the dancer onstage often they insert these tis into one of the dancers orifices while dancing alongside her touching parts of her body and kissing her the women of dukuh paruk will never feel jealous of srintil on the contrary they will feel the opposite their wives feel prouder of their husbands the more they dance with her the public would consider her husband to be powerful due to both his wealth and his sexual skills the payment of a cultural prostitute services the ronggeng dancers sexualized performances are complemented by her work as a prostitute during the period when the dancer is set the profession was legal in java and carried no negative connotations completing her training and graduating by undergoing the bukak klambu ceremony formalizes the ronggeng dancers her role as a highclass prostitute for this service naturally only those who have money can pay the following quotations shows that ronggeng services are very expensive i also know that theres a regional administrator whos sleeping with her its only been a few months already shes wearing a gold necklace her pendant is also made of gold but i bet you dont know who gave srintil her necklace replied another woman that adulterous headman from pecikalan no he replaced the grass roof of sakaryas house with zinc sheeting so who did le hian the chinese man just you watch soon srintil will be wearing gold bangles or maybe even diamond earrings in addition to dancing at night the ronggeng dancer functions as a commodity during the day too servicing vip clients who can afford to purchase special privileges such as private sessions such clients also receive special treatment from the shamans family to ensure that he keeps coming back the vip client for his part might maintain this status by paying in cash or by other means such as giving the ronggeng dancer jewelry or even rendering services to the shaman such as financing the renovation of his home all three types of transaction are depicted in the dancer novel in sum the ronggeng dancer functions as a golden swan for the shamans household after making an initial investment the patron can expect to benefit handsomely from the arrangement in the dancer srintil fully repays what kertareja spent on her virginity contest with the two silver coins the gold coin and the big water buffallo from that point on she ceases to represent an expense and instead becomes a gold mine from which the shaman reaps abundant rewards unbalanced though this patronclient relationship is it is reinforced by a cultural context in which the ronggeng tradition constitutes the pride of the community in the novel at least the ronggeng dancer does not seem to feel that the arrangement is unfair srintil realized that what he was doing was an act of gratitude for the favor of making him a ronggeng conclusion based on this analysis it can be concluded that patronclient relationships are present in javanese performing arts culture particularly in the ronggeng tradition though certain features set them apart from other types of patronage relationahips these relationships involve the exchange of cultural and spiritual as well as economic goods and are sanctioned by divine right and by the community at large moreover there can only be one patron and one client at any given time with her singularity the client is very special and the patron endeavors to meet all her needs though it is the community not the client herself who determines what those needs are these include physical phyisical and spiritual beauty as well as sustenance and shelter the patron is also responsible for preparing all the rituals required to make the candidate a true ronggeng dancer these are expensive and laborintensive but after the ronggeng dancers virginity is auctioned off as part of her rite of passage to become a ronggeng dancerthe shaman begins to benefit from his investments he collects the income that she earns as a dancer and as a culturally sanctioned prostitute unlike the clients in most other types of patronage relationahips then the ronggeng dancer does not render services directly to her patron but rather functions as a longterm investment not unlike the proverbial golden swan elevating the social and financial status of the patron and his family and permanently transforming them into leaders and power brokers in the community

patronklien relationships exist in many sectors of society however few studies have investigated their role in performative javanese dance culture this study aims to explore the representation of a patronclient relationship in the context of traditional javanese dance in a novel ronggeng dukuh paruk by ahmad tohari through literary analysis of narratives and dialogues it elucidates the structure of the patronclient relationship including the roles of the patron and the services the client provides this analysis reveals that the patronclient relationship in the ronggeng tradition is shaped by a cultural context in which no party may unilaterally start a ronggeng group until an indang spirit reincarnates as a human girl a dukun ronggeng may then play the role of patron nurturing the gifted girl and raising her to be a ronggeng he becomes in effect her foster parent and takes care of all her needs including financing her beautification and dance education he also takes on the responsibility of preparing all rituals and ceremonies required to legitimize a ronggeng the ronggeng in turn must repay him for all these expenses with interest by selling her virginity and sexual services to whomever can pay the highest price or by performing her ronggeng dance and passing all the tips she collects to the dukun clearly the dukun functions as a classic patron facilitating a young girl to become a ronggeng and she in turn functions as a client commodifying herself in order to repay and serve her patron

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introduction generation z the generation born between 1997 and 2012 is known for being socially and environmentally conscious this generation is particularly interested in ethical and sustainable practices including the products they purchase businesses that want to appeal to gen z must understand their buying behavior when it comes to sustainable products research suggests that gen z places a high value on sustainable products with 73 of gen z consumers willing to pay more for environmentally friendly products this willingness to pay more for sustainable products is driven by a desire to minimize environmental harm and contribute to positive social change therefore companies that prioritize ethical and sustainable practices are more likely to appeal to gen z as they have a strong preference for brands that align with their values this emphasis on brand values is particularly important for sustainable products as consumers are more likely to trust and support a brand that prioritizes ethical and sustainable practices in addition to valuing sustainability and brand values gen zs buying behavior is also influenced by social media a survey by kantar found that 44 of gen z consumers say they have discovered a new brand or product on social media social media is therefore a crucial platform for sustainable brands to reach and engage with gen z by creating compelling content and using influencers sustainable brands can gain visibility and appeal to this generation the rise of sustainable fashion is one example of how gen zs buying behavior is driving the demand for more environmentally friendly products as fast fashion has come under scrutiny for its environmental impact gen z has turned to sustainable fashion as an alternative a survey by thredup found that 64 of gen z consumers have purchased secondhand clothing compared to 54 of millennial consumers and 44 of gen x consumers this preference for sustainable fashion is also evident in the rise of sustainable fashion brands such as reformation everlane and patagonia in conclusion gen zs buying behavior when it comes to sustainable products is driven by a desire to minimize environmental harm and contribute to positive social change a preference for brands that align with their values and the influence of social media businesses looking to appeal to gen z consumers must prioritize sustainability and ethical practices and use social media to engage with this generation by understanding the values and priorities of this generation companies can create more meaningful and authentic connections with gen z consumers literature review the technology acceptance model the technology acceptance model is a prominent framework in the field of consumer behavior that aims to describe and predict customer behavior regarding new technologies or items it implies that a new products or technologys perceived utility and ease of use is the primary determinant of its acceptability and adoption applying this model in the context of gen z purchasing sustainable products as a result of social media influence it can be suggested that social media exposure to environmental problems influences the perceived usefulness of sustainable products and the perceived ease of use of these products is influenced by their availability and accessibility as a result if sustainable products are presented in a way that emphasizes their utility and are made readily available gen z buyers are more inclined to accept and utilize these items according to research social media can have a significant impact on gen zs purchasing behavior for environmentally friendly products bui et al revealed that social media platforms such as instagram and facebook may influence generation zs views on sustainability and willingness to pay for sustainable items furthermore the availability and accessibility of sustainable products are essential variables in the acceptability and adoption of sustainable products by generation z according to a study conducted by sandström et al the availability of sustainable products is a significant factor in predicting gen zs desire to acquire these items finally because of the impact of social media the theory of acceptance may be utilized to explain and forecast gen zs acceptance and adoption of sustainable goods sustainable firms can boost their appeal to gen z consumers who are more concerned about environmental issues by stressing the utility of sustainable products and making them easily available perceived usefulness this study explores consumers attitudes regarding sustainability labels on clothing and investigates sustainability labels as an effective way to determine customers purchase intent using the technology acceptance model as a framework using selfadministered webbased questionnaires 903 randomly selected shoppers from around the united states provided data the data indicated that the adoption of sustainability labels by customers was related to perceived ease of use perceived usefulness attitude and purchase intention despite the fact that the route links between those parameters did not differ between the two groups sustainability label users scored significantly higher than nonlabel users in all four categories this is one of the first studies to use the tam to study how buyers perceive and use garment sustainability labels because this study concentrated on sustainability labeling and garment purchasing among us consumers conclusions may not be applicable to other product categories or customers outside the us intention to use additionally green consumerism has had a significant influence on the conscious decisions of various enterprises for example several businesses have modified their manufacturing techniques and operational procedures but a products greenness does not ensure that a companys sales will be exceptional in the green age as a result marketers should work to gain insight into the factors affecting consumers purchasing intentions for green products purchasing intentions are critical to comprehend since they can often be utilized to predict customer behavior despite the fact that numerous customers have expressed a more favorable attitude and perception of environmentally conscious organizations the majority of existing consumer behavior research focuses on impulsive or emotional purchasing rather than cognitive evaluation as a result to investigate the correlations between the experimental variables and explain consumers acceptance of and involvement in ecological behavior this study utilizes a theoretical framework based on the theory of planned behavior model ajzen the tpb is an extension of the theory of reasoned action the main difference between these two models is that the tpb includes an additional dimension of perceived behavioral control as a predictor of behavioral intention ajzen proposed that modifying the tpb model to include additional critical factors in a specific context leads to a better understanding of the models theoretical process and enhances the prediction power of peoples intentionsbehavior in a given situation such a strategy according to perugini and bagozzi permits the theory to be extended and developed yeo goh and rezaei used the expanded tpb to recognize visitors intentions jiang and xiong predicted users intent to microblog using a tpb extension perceived ease of use the degree to which a user perceives a certain technology such as accessing websites internet services and web interface usability is referred to as perceived ease of use which pertains to necessary perceived technological qualities more precisely if a technology is more likely to be accepted by online clients it is more useful than another to put it another way the more complex a technological application is seen to be the more likely it is that the website will be used peu and pu are technological adoption characteristics for ecommerce and mcommerce and the desire to use online platform variable hypotheses influence h1 influence has a positive impact on intention to use green purchasing decision factors h2 green purchasing decision factors have a positive impact on perceived usefulness h3 green purchasing decision factors have a positive impact on the perceived ease of use consumer attitudes toward sustainable products h4 consumer attitudes toward sustainable products have a positive impact on perceived usefulness h5 consumer attitudes toward sustainable products have a positive impact on perceived ease of use functionality of sustainable products h6 the functionality of sustainable products has a positive impact on perceived usefulness h7 the functionality of sustainable products has a positive impact on perceived ease of use perceived usefulness h8 perceived usefulness has a positive impact on intention to use perceived ease of use h9 perceived ease of use has a positive impact on intention to use intention to use h10 intention to use has a positive impact on usage behavior table 1 explains the 10 hypotheses in the conceptual research model which is depicted in figure 1 data source the study focuses on the effect of social media on gen zs purchasing behavior of sustainable products via the tam and tpb models however it must be emphasized that in addition to the characteristics described in these models other factors also impact gen zs purchasing behavior of sustainable products a study of the literature on external factors impacting the tam models was conducted these studies have been used to predict gen z customers behavioral decisions regarding sustainable products many empirical studies support new technology and realworld applications by using keywords such as the tpb and sustainable products the literature search was condensed to find relevant papers to verify the uniformity of the articles obtained the following criteria were considered • the articles must have been written during the previous 20 years when the government acknowledged the value of green cosmetics • acceptance of the tam and tpb models and sustainable products should be included in the articles • the procedures findings and outcomes should be reported with complete results presented table 2 presents three external elements intention to use perceived usefulness perceived ease of use subjective norms in addition to contemporary studies have been published nonetheless prior research claims that this variable is employed in the tam as a result the authors considered subjective norms to be possible factors that may directly impact intended use behavior without the intervention of other mediating variables the findings of a study synthesis were utilized to identify common external factors in prior investigations see table 1 research framework and hypotheses influence 311 social norms and social identity peer influence operates through social norms and social identity social norms refer to the unwritten rules and expectations of behavior that are shared within a particular group while social identity is the sense of self that is shaped by ones membership in a particular social group in the context of sustainable consumption peer influence often manifests through the desire to conform to the norms and values of ones peer group as people seek to maintain a positive image among their peers by engaging in behaviors that reflect their values and beliefs this desire for social acceptance can motivate gen z consumers to adopt sustainable consumption practices and purchase sustainable products social media the development of social media has made it a significant platform for peer influence among generation z consumers social media allows gen z customers to interact with a diverse group of peers and exchange knowledge and views regarding environmentally friendly items gen z customers can learn about sustainable products and their advantages through social media as well as regard them as socially desirable or normative within their peer group this in turn can have an impact on their sustainable consumption and shopping habits marketing marketers seeking to promote sustainable products to gen z consumers can leverage the power of peer influence through targeted marketing campaigns marketers can use social media platforms to create engaging and informative content about sustainable products share positive reviews and testimonials from satisfied customers and showcase their brands commitment to sustainability by creating a sense of social norm and identity around their sustainable products marketers can tap into gen zs desire for social acceptance and influence their purchasing decisions green purchasing decision factors conscious consumerism is a movement that promotes mindful purchasing decisions with a focus on sustainability and ethical practices it involves being aware of the impact that our choices as consumers have on the environment and on society as a whole as consumers become more educated about the negative effects of fast fashion singleuse plastics and other harmful practices they are increasingly seeking out brands that prioritize sustainability and ethical production the increased popularity of ecofriendly items such as reusable water bottles bamboo cutlery and cloth grocery bags is one illustration of this trend apart from environmental issues conscientious consumption considers the social effect of products and the manufacturing process this covers things such as fair work standards animal welfare and the use of nontoxic materials customers are increasingly interested in learning about a products full supply chain from raw material sourcing to manufacturing to distribution while conscious consumerism is gaining traction it is important to acknowledge that it is not accessible to everyone many sustainable products come with a higher price tag which can make them out of reach for lowincome individuals additionally not all regions or communities have access to sustainable options overall conscious consumerism is an important movement that encourages individuals to make more mindful purchasing decisions as consumers become more educated about the impact of their choices they are driving change in the marketplace toward more sustainable and ethical practices consumer attitudes toward sustainable products detecting client intentions to purchase green items with social media channel that was considered as new trend in marketing research the purpose of this paper is to investigate the relationships between social media marketing perceived consumer effectiveness product knowledge subjective norms perceived behavioral control price consciousness attitudes and intentions to purchase green products additionally the purpose of this research is to better understand the connections between distinct client segments according to the findings of this study attitude subjective norms and perceived behavioral control positively impact purchase intentions but price consciousness negatively affects purchase intentions customer attitudes and purchasing intentions are influenced by product knowledge whereas perceived consumer effectiveness impacts consumer attitudes as expected social media marketing has a positive effect on subjective criteria functionality of sustainable products with or without modifications the technology acceptance model has been successfully applied in a wide range of empirical studies to predict and explain the acceptance and adoption of a variety of technologies such as electronic banking and social networks as well as understand consumer markets for technological products and services such as online shopping several studies have discovered empirical evidence for the relationships between perceived ease of use perceived usefulness consumer attitudes toward sustainable products and intention to use as shown in the tam each of these considerations prompted bi to employ mobile learning tools the findings regarding the influence of pu on bi on the other hand have been ambiguous in a study on consumer bi to use online shopping vijayasaradhi revealed that peu and pu substantially predicted att which in turn determined bi to use online purchasing therefore the pu of internet purchasing could not explain bi similarly in the case of social media adoption pinho and soares revealed no empirical support for pu and bi customers struggled to comprehend information on the many types of sustainability labels when making a responsible purchase according to empirical studies horne as a result investigating the role of peu in the context of sustainability label usage patterns would be beneficial with the following hypotheses proposed h1a the use of sustainability labels will benefit pu h1b the implementation of sustainability labels will help att the goal of utilizing sustainability labels is to draw attention to a companys environmental and social responsibility statements regarding its products and services therefore unless they perceive an advantage to utilizing it they will not read a sustainability label as a result the following options are suggested h1c the use of sustainability labels will have a favorable impact on att h1d the use of sustainability labels will have a favorable effect on perceived intention research methodology advanced search techniques were used to find scientific articles to gather information on sustainable products the search terms sustainable products environmentally friendly products and ecofriendly products were entered into the subjectdescriptor field and words of title field to ensure consistency only publications in english french and vietnamese were included research design this study collected quantitative data on the factors that influence students choice of sustainable products to achieve this goal a questionnaire was used as the primary data collection method a questionnaire was chosen for this study because it allowed for the gathering of a large quantity of data in a short period of time and at a low cost to ensure the clarity of the questions and statements a pilot study was conducted in an environment similar to that of the main study the results of the pilot study were used to refine and improve the questionnaire furthermore a poll offers a more accurate picture of respondents ideas and attitudes toward environmentally friendly items before administering the survey to the students the questionnaire was reviewed and approved by the groups mentor to ensure its relevance and clarity the questionnaire was created and distributed using the google forms platform which allowed for easy data collection and analysis there are three sections to the questionnaire the first section gathered demographic information such as gender age school year and income the second section explored the factors that impact students selection of environmentally friendly items the relevance of environmental benefits the influence of family and friends the impact of economic factors the effects of social norms the function of health and safety concerns and the influence of brand loyalty were among the variables studied the final section provided statements to assess the dependent variable which is respondents willingness to choose sustainable items over conventional alternatives using a 5point likert scale ranging from strongly disagree to strongly agree the respondents were asked to assess their degree of agreement with each statement the likert scale is a popular technique for testing attitudes and perceptions in educational and social studies overall the questionnaire provided a reliable means of collecting reliable information on the relevant topics in the study the data collected from the respondents were analyzed using microsoft excel and provided valuable insights into the factors that influence students choice of sustainable products figure 2 presents the relationship among the factors for constructing measurement table 3 presents the measurement scale that was obtained from different databases data analysis smartpls 4091 was used to analyze the data for this study results demographic data table 4 shows the respondents profiles the study involved 80 people from across the world with 3375 of those polled under the age of 18 3625 between the ages of 18 and 25 and 30 beyond the age of 25 of the respondents 3375 are young learnerspupils 3625 are students and the remaining 30 are in employment the majority of the surveyed people have a monthly income of less than 2 million vietnamese dong followed by parttimers with an income of 2 to 5 million vnd people earning 5 to 10 million vnd account for 1625 and those earning over 10 million vnd account for only 1375 the number of people surveyed who know about sustainable products accounts for 80 and the remaining 20 know little or nothing about this topic from a social perspective the number of people who always watch influencers use sustainable products and follow them almost is 125 138 do this frequently 425 do this sometimes 313 never do this the number of people affected by price when buying sustainable products accounted for 125 quality accounted for 138 the ability to protect the environment accounted for 313 looking to the future accounted for 275 and userfriendliness accounted for 15 evaluation of sustainable products on the environmental protection scale is 188 cost savings is 188 diversity is 40 and easy to replace and repair is 10 the two functions that influence consumers purchasing decisions the most for sustainable products are environmental protection and easy to replace and repair followed by safety for the user and that with the least affect is no chemicals all factor loadings in table 5 have coefficients above 07 which shows high convergent validity furthermore the ave values reached 05 or more which means that the reliability of the indicators has been confirmed therefore it demonstrates that the constructions fulfill the dependability and convergent validity requirements all inner vif values are in the range of 20 to 50 so the multicollinearity of this investigation is not an issue limitations conclusions and recommendations the purpose of this research is to investigate the impact of social networks on generation zs sustainable product consumption behavior today however there are certain limitations to this study such as the limited research time personnel resources and finance to conduct the study because the data was only collected in select areas and in a limited period of time and the research scope was not broad enough the subjective judgements of the research subjects may have falsified the results sustainable values are becoming more and more essential in our lives especially when crises such as climate change or the covid19 pandemic are causing severe consequences putting the world in danger globe scan experts said that since the outbreak of covid19 people tend to care more about their health so they are more conscious of protecting the environment and preserving natural resources using sustainable products can bring many benefits to consumers and their surrounding environment however for sustainable products to replace conventional products that pollute the environment is very difficult especially for developing countries such as vietnam therefore in order for green consumption to not be lost it is necessary to have the cooperation of the entire community and society specifically the state must develop and perfect the legal framework and implement policies on sustainable product consumption in a synchronous and consistent manner such as promulgating policies to encourage the production of sustainable products and services developing industries and fields of sustainable technology application increasing chemical production prioritizing renewable energy development using resources economically and efficiently and developing green technologies in addition it is vital to build and duplicate green business models while also supporting pricing for green products and services in order to increase customer demand it is necessary to continue to raise peoples awareness about consuming sustainable products and provide children with knowledge about the importance of the environment and how to protect the environment so that each person has the responsibility and obligation to protect the environment companies must continually increase their employees expertise modernize technology to conserve fuel and use renewable and recyclable items they must also endeavor to manufacture high quality ecologically sustainable safe and recyclable products however changing consumer behavior needs time consumer awareness and support the engagement of governmental management agencies and industry collaboration using sustainable products will undoubtedly spread and strengthen over time and as a result customers companies and countries including vietnam will benefit greatly it will also contribute significantly to environmental conservation

the aim of this study is to evaluate the effects of social networks on the consumption behavior of sustainable products among generation z social networks have evolved into important technologies making them an unavoidable option for generation z and the human race in general therefore it is necessary to comprehensively assess how social networks have influenced the consumption behavior of gen z toward sustainable products in order to improve the process of community implementation while improving the quality of social networks and the durability of products a literature review was conducted of studies linked to the suggested study model which includes a mix of social network models and external variables influencing gen zs purchase of sustainable products via social networks the suggested model was then tested on a sample of 100 vietnamese students social networking techniques were used to study and evaluate the dataset the report advises that managers and marketers should employ social media marketing tactics to communicate with gen z customers and promote the value of sustainability management and marketers should also provide sustainability information and promote sustainable goods on popular social media platforms such as instagram facebook twitter and tiktok

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introduction internet has become an indispensable part of our lives due to the rapid progress of developments in information and communication technologies in the 21st century thanks to internet individuals reach desired information any time and communication between individuals in different places of the world is becoming easier main aim in the education system is success studies and new searches for improving success highlight the system of governance in education success is a chaotic topic and it is linked to more than one factor for example for these factors countries historical savings political and economic situations the sum of sources that are reserved for education qualifications of teachers family styles the importance that is given to education by political structure and physical opportunities of educational institutions can be counted technology and internet leads to changes in several areas including education and training 1 2 emphasized in their study that integrating information and communication technologies in learning and teaching processes was necessary in order to increase student performance information and communication technologies not only facilitate learning they also help effective learning 345 the study of 3 underlines the importance of digitalization and changes in school systems through the importance of technology in addition having a culture in school within the framework of adoption and diffusion of technology is crucial for making professional development and innovation especially with web 20 technologies individuals communicate with each other make friends and share videos photos course contents etc using social settings using web 20 tools in education ensures that learners enjoy permanent learning 6 undertake the responsibility of selflearning strengthen their relations with group works and improve advanced thinking abilities 7 social networks which are products of web 20 technologies allow online chat and content sharing as well as introducing oneself by means of areas of interest personal information and photographs they also provide an environment where students can interact using their works and participate in cooperative formations the fact that todays students can effectively use social networks has been noticed by teachers and studies were initiated on how to use social networks as a tool for learning and teaching 89 effective use of social networks in education settings provides such advantages as increasing the learning of students including them in learning processes improving their motivation developing their writing skills and facilitating teacherstudent and studentstudent interaction 10 social network settings not only make learning and teaching in classroom environment easier they also provide effective learning environment to people outside the classroom contrary to these advantages it is stated that using social networks in education settings can affect learning process in negative direction 1112 the study of 13 gives an insight of being global citizenship and underlines the importance of having technological and managerial skills in the transformation of education in this respect being leader and managing technology become crucial to foster knowledge construction 14 social networks become people to be connected and exchanging the ideas information it becomes medium of learning and make learners be active and inclusive to the learning context although social networks have positive sights it is claimed that using social networks compromise the authority of the teacher in classroom 14 and that increase of usage frequency is correlated with the decrease of average grades of students 1516 according to 15 teachers and parents make more deliberate use of social networking sites due to such problems and that some schools have even banned the usage of social networks opposite to claimed discussions educative social network sites play a great role to induct learners to the learning context and emerge the uses of technology in interaction and collaboration edmodo can be given as an example to such sites educative social networking sites allow for teachers and students to use social network technologies for educative purposes they also ensure that security and confidentiality problems can be minimized 17 the fact that edmodo is similar in its appearance to facebook which is one of the most widely used social networking sites increased its popularity among students 17 edmodo is a global education network which helps all students to connect people and resources which they need to fully realize their potentials the advantages provided by edmodo to teachers are as follows nonregistered people do not have access to the site teachers can prevent uncontrolled participation in classes and it provides a secure education environment which prevents abuse of information on students for malign purposes 17 the uses of blockchain is a new platform for the school management the applications in storing records learning identity verification information security lifelong learning for the ownership and protection of content make the potential value of blockchain in education school management has an intensified need to moderate merits of blockchain by increasing the capacity of participatory management through the uses of blockchain system in this respect school management gains a value for the trust security through the uses of block chain the subjects of governance and data mining are new therefore education administrators have not got information at sufficient level to foster learning 18 with the development of mobile connected and personal technologies mobile learning has become a basic tel paradigm with the merits of blockchain system mobile learning emphasizes the use of mobile devices and unlike traditional types of education focuses on student mobility it also emphasizes that learning can take place anytime and anywhere without the limitations of time location and environment designs that combine both real and virtual learning environments are significant in intelligent education as the blockchain system become a merit for the qualification and verification of school management partnership collaboration and support for to open opportunities for the school environments to reconsider and use new learning structures become important all data that will be obtained from every shareholder during the process of governance should be evaluated healthfully and a mechanism which will produce administrative results from the available sources should be created data mining comes first among the important tools for this process blockchain application in education especially in school management plays a great role to gain trust and security for the quality 19 the uses of blockchain models in management especially in schools make decreasing the costs and increasing the validations it has been witnessed in the literature in recent years that educative online settings have made contribution to education environments they particularly provide an effective learning environment in terms of increasing interaction between students continuing communication after the class and integrating these settings in the course process for more permanent learning in this sense it has been essential to examine the role of edmodo in learningteaching processes as an educationoriented social learning network 20 today there is need for individuals who are able to think produce apply what they think and find solutions to problems integrating new technologies applications and settings in learning and teaching processes in educating such individuals is essential so as to ensure effectiveness of learning in this case it is particularly necessary to ensure the adaptation of teachers who will integrate these innovations in learningteaching processes to new technologies or applications in this context keeping teachers posted about these innovations displays the essence of this research currently in addition to the practices implemented for teaching in learningteaching process the change in learning settings is remarkable it is clear that educative online settings make contribution to learning and teaching processes increase student motivation for the course and make positive contribution to education settings in this context the purpose of this study is to examine the use of edmodo which is an educative online setting for teachers aiming at evaluating edmodo content management system education which is designed for secondary school teachers and to gain opinions concerning the usage of edmodo in learningteaching process the subobjectives determined in order to reach this goal are as follows • what is the level of secondary school teachers as regards edmodo content management system • what are the opinions of secondary school teachers concerning the usage of edmodo content management system in learningteaching process • what are the opinions of secondary school teachers concerning awareness in the end of edmodo content management system seminar materials and methods in this section detailed information is given on research model study group data collection process data collection tools research process and application preparation of education setting application and the role of the researcher model of the research the objective of this study is to provide education on edmodo to secondary school teachers at ministry of national education of turkish republic of northern cyprus and obtain the opinions of these teachers on edmodo thus the study was conducted using qualitative research method 21 defined qualitative study as a knowledgeproducing process with a view to understand the lifestyles stories behaviors organizational structures of people and social change in the research case study model has been used among qualitative research methods case study is a method which examines one or more cases situations settings or interconnected systems in depth 22 understanding the case is an essential element of data analysis which deserves elaboration data are mostly obtained from interviews field observations and documents 23 study group the pilot study group of the research consists of 138 of the 221 teachers who worked at near east college in academic year the study group which received education in the study consisted of 21 volunteer teachers who worked at secondary level and participated in usage of edmodo content management system series of seminars data collection process in the data collection stage of the study needs analysis was conducted with the purpose of determining the knowledge skill and experience level of teachers as regards edmodo content management system semistructured interviews were conducted with teachers using interview forms and these interviews were recorded later the interview records were transcripted prior to attending at usage of edmodo content management system seminar a preliminary evaluation form was used in order to determine the preliminary information level of teachers concerning edmodo then a final evaluation for was applied with the purpose of determining the acquisitions of teachers at the end of the seminar data collection tools during data collection needs analysis was conducted as the first step in the needs analysis 3 openended interview questions were prepared which were developed by the researcher with the purpose of determining the information level of teachers at the stage of preparing openended interview questions literature search was conducted and problems and expectations were taken into consideration while preparing the openended questions recognized principles were taken into consideration and attention was paid to ensure that they were understandable free from direction and multidimensionality made use of alternative questions and were organized in a logical order 24 the prepared openended questions were evaluated by 2 field experts 1 language expert and 1 measuring and assessment expert based on the feedback provided by the experts corrections were made and the final form was given to the questions in addition other data collection tools used in the study were preliminary evaluation form and final evaluation form preparation of education setting and designing of materials at the preparation of education setting stage as it would be possible to follow the facetoface classes online at uzemneuedutr address an application was filed to distance education centre directorate of near east university this system was chosen because the participants were knowledgeable about the usage of edmodo content management system it provided a highquality education setting and it was a course management system which was previously experienced application usage of edmodo content management system seminar consisted of 21 participants who worked at secondary stage of ministry of national education schools participants who attended the seminar brought their laptop computers with them those who did not have their laptop computers participated in the class using their smart phones wireless internet was provided to the participants at the classroom where the seminar was organized course contents were prepared using microsoft power point program and reflected using a projection so that participants could follow in addition application was performed with participants and edmodo program was covered step by step at the end of each class course contents were uploaded on uzem system by means of an audiovisual video which was produced using camtasia 9 studio program analyzing and interpreting the data in the study interview questions prepared in order to determine the needs of teachers working at secondary stage concerning the usage of edmodo content management system findings obtained from needs analysis findings obtained from preliminary evaluation form and findings obtained from final evaluation form were analyzed based on their answers using content analysis method reliability and validity in order to ensure the validity and reliability of the study internal validity external validity internal reliability and external validity actions were taken researcher and role after having obtained the necessary permissions required for performing the needs analysis in order to determine the problem the researcher passed on to application stage in the light of identified needs preparations were launched for the education seminar which was delivered by the researcher to teachers who worked at secondary stage seminar promotion posters were prepared and teachers were informed seminar topics were organized using power point presentation program in addition course contents which were uploaded to distance education center system were prepared using camtasia studio 9 program following the preparations seminar process was initiated finding and interpretations in qualitative research process the perceptions of participants concerning edmodo content management system application and obtained findings are included findings on needs analysis in the needs analysis 138 of the 221 teachers answered the questions needs analysis questions consist of 3 openended questions the themes related to the openended interview questions are given below need analysis becomes an evidence on understanding the nature of awareness on the use of new application in education context and learning process an examination of table 1 shows that among the 138 answers to the question what is the contribution of edmodo application to language education 26 people mentioned effective communication opportunity 18 people said it had positive contribution 17 people said it has no contribution and 77 people said i have no information and thus did not answer the question these questions shed a light on the awareness on new application in language education an examination of table 2 shows that among the 138 answers to the question what are your opinions and recommendations as regards edmodo 11 people said it affects education positively 6 people explained it is not an effective system 1 person said lack of infrastructure it is witnessed that 120 people did not answer the question as they did not have any information it is clear that a majority of teachers do not have adequate information concerning edmodo content management system an examination of table 3 shows that among the 138 answers to the question do you think that edmodo application has deficiencies 2 people indicated technological infrastructure deficiencies 4 people said it has deficiencies 11 people said it has no deficiencies and the remaining 121 people did not answer the question as they did not have any information on the application findings obtained from preliminary evaluation form preliminary evaluation form consists of 4 openended questions below themes related to openended preliminary interview form are provided an examination of table 4 shows that among the 31 answers to the question what are your opinions as regards using edmodo 16 people provided positive opinions whereas 15 people stated that they did not have any information on the application an examination of table 5 shows that among the 31 answers to the question briefly define edmodo content management system 18 people indicated social education network and 13 people said that they did not have any information on the application an examination of table 6 shows that among the 31 answers to the question what are the contributions made by edmodo to learning process 18 people stated fast communication and 11 people said that they did not have any information on the application research participants underlined that edmodo applications makes learning smarter by adding a value of communication and it makes a need for upgrading knowledge on this new application an examination of table 7 shows that among the 31 answers to the question what are the contributions made by edmodo to learning process 11 people stated that it supported individual learning 6 people said education opportunity outside school and people 14 said that they did not have any information on the application findings on final evaluation based on the outcomes of training final evaluation questions consist of 6 open ended questions themes regarding openended final evaluation questions are given below after the series of seminars as can be seen in table 8 to the question i have detailed information on the nature of edmodo content management system 21 people stated that they had information about edmodo table 9 findings concerning the answers given to the question i know the impact of edmodo content management system on learningteaching process in the final evaluation form teachers the impact of edmodo on learningteaching process f it affects learningteaching process positively 21 as can be seen in table 9 to the question i know the impact of edmodo content management system on learningteaching process 21 participants answered that they had information on the impact of edmodo content management system on education process this shows that research participants increased the awareness on changing learning contexts by the use of technology table 10 findings concerning the answers given to the question i know that edmodo content management system makes contribution to the professional development of teachers who use it in the final evaluation form teachers contribution of edmodo to professional development f it affects professional development positively 21 seminars are tools for the professional development as can be seen in table 10 to the question i know that edmodo content management system makes contribution to the professional development of teachers who use it 21 people answered that they had information on the impact of edmodo content management system on the professional education of teachers as can be seen in table 11 to the question i have information on the usage of edmodo content management system 21 people answered that they had information on using edmodo as can be seen in table 12 to the question i have information on what can be done as teacher student and parent in edmodo content management system 21 people answered that they had information on the characteristics of edmodo as can be seen in table 13 to the question please write down the knowledge and skills you acquired on edmodo content management system in the end of the seminar 21 people stated that they were knowledgeable about the characteristics of edmodo conclusion and recommendations the conclusions obtained from the research are explained consistent with subobjectives and findings knowledge level of teachers concerning edmodo content management system within the framework of the research a preliminary evaluation form was applied in order to assess the knowledge and skill levels of teachers concerning edmodo content management system prior to the 10 hours seminar applied to the teachers the prepared preliminary evaluation form was prepared taking the content of the seminar into consideration after the seminar a posttest was prepared and applied so as to evaluate the knowledge acquired during the study seminars were organized to make a change of according to the obtained findings it was found out that teachers did not have adequate information on edmodo content management system before the seminar but that their awareness related to edmodo increased after the series of seminar which was shown by their answers 25 obtained the same conclusion in their study opinions as regards the contribution of edmodo content management system on learningteaching process another subobjective of the study was the contribution of edmodo content management system on learningteaching process when we examine the foregoing it has been found out that the teachers who attended the seminar did not have adequate information about edmodo content management system prior to the seminar during the seminar which continued for 5 weeks information was given to the teachers on edmodo content management system and its usage and several applications were performed teachers who attended the seminar entered edmodo system both as student and teacher and contributions that edmodo content management system could make to learningteaching process were discussed at the end of the seminar process participants stated that they supported the view that edmodo content management system could be effective on learningteaching process in their study 26 concluded that 50 of students stated that edmodo increased their learning 27 argues that edmodo ensures healthy communication not only in classroom environment but also outside the classroom 43 opinions of teachers concerning edmodo usage at the end of edmodo content management system seminar by means of edmodo learning environment teachers can increase the motivation of students for the class reach students easily perform group works and support cooperative learning participate in groups in various parts of the world and follow the developments in their field and other fields which in turn contributes to their professional development in this study the participants were not knowledgeable about edmodo content management system prior to the seminar but they provided positive opinions about edmodo after the seminar this result is similar to other studies in the literature 2728 as edmodo has a multifunctional learning and teaching opportunities through infrastructure and learning styles after series of seminars research participants recognized the merits of group work cooperative learning which make their learning motivation to the learning tasks recommendations taking the contributions made by technology to education today encouraging activities can be performed for the teachers to use edmodo content managerial system which is free easytouse and safe for information sharing in their classes in order to make learning environment more efficient edmodo content managerial system can be used to increase the responsibility of students towards the class in their learning environment as schools are change agents to diffuse create knowledge through the merits of technology professional development can be gained and school can make adoptions to be smart learning context when they become smart learning context there is an intensified need to create technology supported learning and teaching environments being a leader of managing learning environments through the use of new technology and application is essential therefore teachers as leaders of classrooms need to upgrade their knowledge in the use of towards digitalization within the mission of this way entrepreneurship and innovation in schools through the managerial and technological attempts are essential 2728 school administratorsleaders should consider many factors in order to provide successful education these factors are curriculums economic sources competition and regulations in modern education systems school administrators should work with many stakeholders with an interactive way school governance foresees that all stakeholders should be involved in decision making process in order to increase human rights values 31 headmasters and teachers as partners of school culture need to concentrate on the use of edmodo in order to support learning and teaching this way of learning become a step to diffuse digitalization to make smart learning context in order to enhance learning 32 teachers in different parts of the world in the same branch can meet at certain times in edmodo settings and transfer each other new technologies and methods they use in their classes for this reason it is recommended that teachers at secondary stage should be member of edmodo so that they can obtain contribution to their professional development and knowledge of field both educators administrators and learners can benefit blockchain powered applications educators can efficiently use this kind of application for storing or sharing teaching material or activities on the other hand administrators can record degrees of students and open access for other institutes 18 blockchain will provide administrators to make their organizations more secure and reliable moreover blockchain will allow learners to access to education easier and more affordable as the blockchain applications are decentralized directly communicating with educators is possible 33 this study was conducted with teachers at secondary stage of ministry of national education further studies are advised to consider different sample groups teachers can cooperate with parents using edmodo learning environment and increase the responsibly of students towards class technology which exists almost in every part of life has started to make traditional methods become insufficient in every field therefore especially in 2000s studies and searches for new methods have seriously increased ministry of national education is advised to develop educative learning environments according to education needs and infrastructure 29

schools are social agents to diffuse merits of technology the uses of technology foster professional development schools have started to make tendencies towards digitalization especially learning and teaching contexts become technology supported in this respect school infrastructure and learning resources have changed teachers play a great role to adopt new changes in learning teaching process to the new generation this makes innovation in schools to use new technologies and applications for better education practices this research study aims to create awareness on edmodo model to teachers and develop their skills on new learning contents for establishing more digitalized school at the secondary education level and analyze the uses of blockchain in school management the research study was conducted with 21 volunteer teachers working at the secondary level that they get training on the use of edmodo content management system case study through action research was done in this research study that selfreport was used to gain experiences of teachers by this way educational online environment was created for teachers for the uses of learningteaching process research results revealed that teachers enhance their skills and knowledge about the use of the edmodo content management system increased compared to the preseminar in addition they gained online collaboration and research skills this practice created the culture of technology based innovation for their schools

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loneliness and social isolation are a high priority problem for ageing populations around the world loneliness and social isolation are often a consequence of mobility constraints bereavement declining social networks or physical relocation and have been proven to be closely associated with poor mental and physical health outcomes international studies have estimated that between 5 and 16 of older adults experience loneliness 12 decline in mental and physical health influence and are influenced by loneliness for example restricted physical mobility reduces engagement in social activities which can further lead to depression or loss of appetite 3 increasing the chances of rapid decline in health condition contact with family and friends is important for perceived social support 45 and participation in social events plays a role reducing risks of depression anxiety and cognitive impairment 6 voluntary sector befriending schemes have been found to be effective in reducing loneliness monk and reed 7 describe a befriending scheme in london that uses telephone conference calls and weekly onetoone calls to connect older adults over the phone they found that the users perceived an intrinsic benefit in actively engaging or listening to a conversation regular contact also provided reassurance and instrumental gains through information sharing king et al 8 report the benefits of telephone reassurance service for older adults living at home initially the scheme was set up for emergencies but was later found to play an important role in providing a sense of security and wellbeing a number of studies have also demonstrated the potential role of internet communication technology in reducing loneliness and improve quality of life among older adults at risk of isolation white et al 9 explored the effect of internet use in a retirement community and demonstrated through assessments that reconnecting social ties decreased level of loneliness similarly groves and slack 10 explored the impact of a computertraining programme with 20 nursing home residents preand postevaluations showed an increase in independence and engagement in social activities internet communication technologies offer individuals new ways to help remain connected with peers and family members in a flexible and inexpensive way however technologies of this type are often inaccessible to the older section of the population due to decline in cognitive sensory and physical abilities furthermore many older adults especially those in the late stages of the life course are not regular computer users and would experience problems with interface conventions terminology and operating system 1112 numerous studies have explored the design requirements for email systems that can be easily used by older adults with little or no computer experience 111314 czaja et al 13 developed a simple messaging system to support social connectedness among 36 women between the ages of 55 and 95 with little computer experience the trial lasted for 6 months and it was found that the users could work the system with a minimal amount of difficulty and that they found it useful importantly participants indicated that the system facilitated social interaction and provided a chance to meet new people however a significant decline in use over time was also found this was attributed to the fact that people were busy and the system had limited functionality this seems to indicate that although the system was easy to use it needed to be perceived as useful in order for it to be adopted in the long term the system would need to be expanded without unnecessarily increasing its complexity purpose of the study during summer 2009 the building bridges system was deployed in a home trial with 19 older adults for 10 weeks participants included a diverse range of older adults with considerable variation in levels of social connectivity and experience with technology in addition 17 friends and family members were nominated at the discretion of the participants to use a client version of building bridges this cd version can be quickly installed on a standard pc and allowed secondary participants to also participate within the network the study was designed to obtain an insight in how the system could be used in a realworld setting and explore how such a system impacted on participants social connectedness the aim was to deploy technology in the home as less intrusively as possible unlike most communication technologies this system is designed to provide opportunistic social interaction in a nonintrusive way to encourage social interaction among strangers through analysis of system usage and users experiences the study reports how the system was used by primary participants implications for designing recreational technology to support social connectivity in order to reduce risks of isolation are also discussed the building bridges system drawing from previous research around loneliness among older adults the technology research for independent living centre developed a device as part of the building bridges project to encourage peertopeer social engagement among older adults the device consists of a 12inch touch screen computer in a custommade stand a phone handset with functioning cradle and speakers the software uses voip with a customised flashbased interface developed with participation from older adults that allows users to interact with four main features these features are briefly described here broadcast and chat users can listen to regular broadcasts a guide to the broadcasts can be viewed on the left of the main menu screen at the scheduled time a message appears on the screen inviting the user to listen to the broadcast if they wish to listen they press a button on the screen during the broadcast icons that represent other people who joined are shown on fig 1 the building bridges device displaying the main menu screen the right of the screen when the broadcast is over the user can join a group chat with the other listeners by lifting the phone handset during the group chat the screen displays visual cues to support the conversation calls users can make calls to one or more people to start a call the user presses the button labelled make a call on the main menu screen this leads to another screen showing a list of other people they can call they then select the person they wish to call if the person they wish to call is not available the icon is shown as grey and a red cross appears in front of it when pressed once all contacts are selected the user presses the button labelled call during the call the user is provided with the same display as the afterbroadcast chat without the counter figure 2 presents an image of the group chat display messaging users can write messages that are up to 160 characters long to write a message the user first presses the button labelled write message this leads to a screen presenting a touch screen keyboard the letters are arranged alphabetically on the keyboard if the user wants to use numbers or punctuation in the message they are required to press a button that changes the keyboard mode similarly if they wish to use capitals a separate button is used to change the mode from lowerto uppercase tea room the tea room is an audio chat room that users can access anytime day or night the user enters this by pressing the button labelled visit tea room on the main menu screen if another person entered their icon would show up on the screen users needed to lift the handset to talk but they can also listen to ongoing conversations through the speakers during the trial classical music was played when the room did not include any other people a series of background pictures from web cameras positioned around dublin were also displayed on the screen method sample this study included two sample sets the primary participants were 19 older adults who were provided with broadband connectivity and a building bridges device the secondary sample included their friends and family members who volunteered to use a pc client version of the software on their own computers this allowed the primary participants to contact their own friends and family via the system as well as the other primary participants this paper focuses on the data from the older adult users secondary participants engagement with the system is taken into account only when they were recipients of calls and messages from primary participants primary sample there were 19 primary participants aged between 65 and 84 and were recruited through the technology research for independent living research clinic at st jamess hospital in dublin the tril clinic offers a comprehensive geriatric assessment to communitydwelling people over 60 years of age in ireland assessments include physical health cognition mood and social connectedness all participants lived in their own homes in dublin or surrounding areas of these 47 lived alone and the remaining 53 lived with a spouse the majority did not own a computer according to the dejong loneliness scale 16 6 of the participants were classified as socially lonely and 5 as emotionally lonely loneliness is a subjective state of negative feeling associated with perceived social isolation whereas social loneliness stems from a perceived lack of social contacts or engaging social network emotional loneliness is perceived as arising from the absence of an intimate relationship or close attachment it has been suggested that social loneliness can be associated with a lack of social integration and emotional loneliness is the result of psychological factors 17 table 1 lists the 19 participants and background characteristics as identified through the tril clinic as the study is exploratory a broad range of participants were included fig 2 the screen display during a group chat in relation to age loneliness and experience with computers friends and family the 19 primary participants were asked to nominate family and friends to use the pc client version of the software nominees that agreed to take part were provided with the software a user guide for installing the software and usb phone handsets the pc client allowed them to make calls and messages the participant that nominated them they could also access the tea room however they did not have access to the broadcast feature as this was exclusively meant for the 19 primary participants there were 17 pc client users in total eleven of the primary participants had at least one pc client contact ethics participants were required to provide informed consent before taking part all were provided with an information sheet explaining the purpose of the study the data being collected and how long they would have the technology all participants were provided with a contact telephone number if they needed any assistance with the device they could also contact the researcher via the system itself using the calls or messaging features it was emphasised to all participants that they could use the system as much or as little as they liked and should not feel obliged to use the device at anytime participants were not provided with personal information or contact details of the other participants all names presented in this paper are pseudonyms procedure and support each primary participant was given the building bridges device for 10 weeks they were told to use it as much or as little as they liked the device allowed participants to use all four features described in sect 2 each primary participant could contact the other primary participants through the system as well as their respective pc client users the trial included four separate home visits and one focus group with all participants a month after the conclusion of the home deployment visit 1 recruitment researchers visited the participants homes to explain the purpose of the project and describe the device participants were also asked to identify any friends or family members who may be interested in receiving the pc client version of the software an information sheet was left with the participants along with information leaflets for any friends and family who wished to be involved visit 2 entry interview the interview took part in participants homes and included a semistructured question script focusing on health social routines changes to social network and experience with technology visit 3 deployment and training the device was installed in homes in a location of a participants choosing by the researcher each participant was shown a short video lasting 6 min which described the system they could access the video at anytime during the trial by pressing a button on the touch screen the researcher then demonstrated each feature to the participant and showed how to turn the device onoff visit 4 exit interview at the end of the trial the researchers removed the device and conducted an exit interview with the participant this focused on the user experience with the system and perceived impact on their social connectedness in addition the researchers carried out a system questionnaire with participants the device was then removed from the home focus group one month after the trial had concluded the 19 primary participants were invited to a focus group and lunch it provided an opportunity for the participants to formally meet each other in person for the first time exchange contact details if desired and discuss their experiences with the system along with their views about how it could be further customised or improved the participants were able to contact the research team at anytime during the trial this could be done via the messaging feature by sending a message to a tril help contact a contact phone number was also left with all participants in addition weekly calls were made to each primary participant to report any technical issues such as system breakdowns for continuity the participants interacted with an assigned researcher throughout the trial data collection and analysis use of the system was logged remotely for each primary participant this included the time frequency and duration that each feature was used the participants were aware their usage was being logged a repeated measures anova was used to test the main effect of time over the 10 weeks the greenhousegeisser 18 threestep approach to significance testing was employed when relevant in this case the uncorrected degrees of freedom the corrected p value and the epsilon value of the correction factor are reported post hoc t tests were calculated to compare use between the first half and second half of the trial the relationship between system use and background characteristics including gender experience with computers living alone and loneliness was also explored using t tests however it is worth noting the limitations due to the small sample size exit interviews and focus group were audio recorded and analysed to identify common themes occurring across the different cases themes emerged through a collective analysis of data in which researchers presented case notes from their respective participants to the rest of the research team during these presentations key issues and insights were captured via postit notes once all cases had been presented the postit notes were grouped and categorised on a white board to highlight themes results system use broadcasts there were 125 broadcasts in total played between 11am and 8 pm everyday table 2 summarises broadcast types length ranged from 6 to 30 min there were five main broadcast types news a soap opera documentaries health and entertainment nearly all broadcasts were obtained from internet sources six of the health broadcasts were created by tril research team overall 104 of all broadcasts were attended by at least one person overall 74 of broadcasts were attended by two or more people and 28 of all broadcasts led to a group chat health broadcasts showed the highest rate of attendance of two or more people and highest rate of chats the broadcast type least likely to lead to a chat was the soap opera followed by the news broadcasts just over half of postbroadcast chats were between 2 people 25 included three people and 21 include 45 people the average duration for postbroadcast chats was 4 m 44 s on average health broadcasts led to the longest chats one chat lasted the full 20 min which followed a health broadcast on brain fitness the shortest postbroadcast chat followed the soap opera and lasted just 9 s figure 3 shows the number of broadcasts attended by two or more people and frequency of broadcast chats over the 10 weeks there was a significant main affect of time on broadcast attendance over the 10 weeks f 55 e 4 p 01 however a repeated measures ttest did not show a significant change in attendance rate between the first half and the second half with regard to postbroadcast chats there was a significant change in attendance observed over time f 35 e 03 p 05 post hoc analysis revealed a significant drop in attendance to postbroadcast chats between the first half and the second half t 27 p 05 attendance to broadcast was significantly higher for female participants than male participants t 23 p 05 female participants also attended more postbroadcast chats t 22 p 05 attendance to postbroadcast chats was also related to loneliness in which those identified as emotionally lonely attended more frequently than those who were not social loneliness living alone and experience with computers were not found to have a significant relationship with this feature participants reported the opportunistic nature of talking to other people after a broadcast this would often include people who they would not have otherwise thought to contact one male participant likened it to a social encounter in a public place it was the typical lamp post at the corner of the street and three or four chatting some who were reluctant to initiate a call also considered it to be the main opportunity to chat i was too shy to make a call… i would talk to people after the broadcast the shared experience of the broadcast also provided a topic of conversation even for those participants that were less active in calls and messages we were talking about the broadcast because that was the common bond and you had the men join in then these accounts indicate that broadcasts fulfilled their design purpose in somewhat encouraging social interaction by the provision of an opportunistic discussion topic however as the chats were not facilitated some reported difficulties in following the conversation or breaking into it some participants joined the postbroadcast chat in moments when participants were talking about intimate issues and felt disinclined to reengage calls in total 361 calls were attempted by the primary participants of these 187 were answered by the recipient out of the conversations that took place 47 were between primary participants and 53 were between primary participants and their respective pc client nominees any calls made to tril help were excluded from the analysis figure 4 shows frequency of answered calls across the 10 weeks there was no significant change in use of this feature observed across the 10 weeks figure 5 shows the average duration of calls over the 10 weeks average call duration between primary participants was 8 min 40 s there appeared to be an increase in call duration for example week 1 showed the shortest average call duration and week 10 showed the longest average call duration however no significant change in time spent using this feature was observed over the 10 weeks similarly call duration with pc client users peaked towards the end of the trial the highest average being in week 9 and the lowest in week 1 but no significant change in duration was observed analysis of participant background characteristics revealed that females had significantly more calls with other primary participants than males t 23 p 05 loneliness was also associated with this feature since those identified as socially lonely had more calls with other primary participants t 24 p 05 living status and experience with computers were not found to be significant factors in using this feature the majority of calls between primary participants were onetoone conversations only 7 group calls took place over the 10 weeks outside the broadcast chats and tea room conversations it appeared that the low frequency of group calls was partly related to lack of awareness about this feature i didnt know you could make a group call that would have made a difference participants generally associated the group chat feature with the broadcasts or the tea room and many did not register that they could initiate their own multiperson calls this was despite the fact that group call procedure was the same as that used for sending a group messages and that this functionality was also shown during the deployment and training visit and was included in the introduction video messages in total 574 messages were sent by the primary participants fiftytwo messages were group messages for the purposes of analysis group messages were counted as one message the majority of messages sent were to other primary participants the remaining 21 were sent to pc client users any messages sent to tril help were excluded from the analysis figure 4 shows the frequency of messages sent to other primary participants and pc client users across the 10 weeks figure 6 shows frequency of messages sent over 10 weeks on average 45 messages were sent to other primary participants per week this ranged from 17 to 94 there was a significant main effect of time on frequency of messages sent to other primary participants f 34 e 5 p 05 repeatedmeasures ttest showed a significant drop in messages sent to other primary participants from the first half to the second half of the trial t 21 p 05 on average 12 messages were sent to pc client users per week there was also a significant main effect of time on frequency of messages sent to pc client users f 36 e 3 p 05 however the difference in messages sent between the first half and second half was not found to be significant background characteristics associated with use of messaging included gender in which females sent significantly more messages than males t 36 p 05 and loneliness in which those who were socially lonely sent significantly more messages than those who were not t 22 p 05 living status and experience with computers were not significant factors in frequency of messages sent according to the participants the messaging had the dual purpose of lightweight social interaction and an instrumental role for arranging a call or meet up in the tea room as well as outside of the system last saturday a message said these women were walking in the park and i would have been interested in that i would have done that some of the comments seem to highlight an increasing intimacy of the message content through time it got more friendly and more personal how are you and mind yourself for simplicity the word limit was restricted to the writing space on the screen which means that up to 160 characters could be used in one message this constraint allowed for recommended font size for the user group and avoided added complexity to view text beyond the writing space such as scroll bars however utilising this constraint enforced unexpected limitations for the users many wanted to still write longer letters in conventional form rather than the short hand text language they also wanted to maintain standard letter openings and endings as would be used for letters or postcards consequently the space allowed in the writing space was not sufficient for the participants tendency to avoid abbreviated language also added an extra step of planning before writing the messages you had to think what can i say… it would have to be short tea room on average the participants entered the tea room 40 times over the course of the trial there was a large range across participants for example grace made 196 entries in total spending just over 81 h 18 min in the tea room in contrast bert spent 3 min 36 s in total across 10 entries unlike the other device features the tea room is a state of the device as opposed to an event and therefore the use of this feature does not necessarily reflect social interaction for example a user may keep the tea room application open but leave the house therefore time duration of use is not reliable for assessment of social interaction at the same time the number of accesses throughout the day was also not a reliable indicator of social interaction as some participants liked the music and stayed alone in the tea room to listen while others accessed and left it many times throughout the trial to check if someone was in however participants comments about their experience of the system provided some insight into how it was used there were quite polarised attitudes towards the tea room as some people loved it while some people did not among some of those who did not like the tea room some found it difficult to join in on a conversation on the other hand the tea room also had some great proponents in particular two participants selfdefined by one of them as late night birds liked to use the device in the evening and often late into the night the tea room presented a very good option to see whether someone was online without calling or sending messages that they perceived as inappropriate late in the evening perceptions of the system an exit interview and system questionnaire was carried out to support log analysis and explore perceptions of the system the questionnaire was a shortened version of the system questionnaire devised by czaja et al 13 table 3 summarises responses to the system questionnaire sixtyfour per cent of the sample reported that they were satisfied or very satisfied with the system as a means of communication the messaging was ranked as the most preferred feature of communicating followed by calls the majority of the participants said that they liked the system because they found it easy to use liked meeting new people and liked communicating with others fortyone per cent reported that they wanted to use the system to socialise with other people however over half also reported using the system as part of the study main reasons for not using the system included being busy on holiday or illness just under a third reported that there was limited use of the system discussion this paper has reported the usage and experience of older adults using a novel communication system designed to support social participation and connectedness the findings show the potential for using internetbased communication technology as a means for encouraging social interaction in a flexible and unobtrusive way the work builds on previous research showing the promise of providing group interaction over the phone and the benefits of making internet communication more accessible to older adults the system used in the current study was designed to provide opportunities for onetoone and group interaction with new people in this case calls did not involve a facilitator instead opportunistic interaction was stimulated through daily broadcasts integrated by the calling messaging and chat room features this pilot study provides insight into how this new system is used in realhome settings it provides further insight into how such technology should be developed so that it fits with what potential users need and want the remote logs of system use along with exit interviews provided insight into how the system was used it should be noted that as the study includes a small sample size the results cannot be generalised however it provides further understanding into how users engage with the system and socialise through the technology engagement with the system when a new technology is introduced engagement with the system may be more of a reflection of its novelty as opposed to usefulness other studies have previously highlighted this novelty effect when piloting new communication systems with older adults 13 the novelty effect refers to when engagement and persistence with technology is high at the early stages simply because it is new usage generally peaks at the beginning and steadily declines over time although a drop in use of the call feature was observed between first and second half of the trial this change was not found to be statistically significant the trial length might have affected the novelty effect and a longer study might have shown novelty effect more clearly the lack of statistically significant drop in usage may also be partly connected with the sharp increase in use during weeks 9 and 10 for calls this wave of increased use may be due to participants awareness that the deployment was due to end the perceived final phase of the trial might have been seen as the last opportunity to engage with each other the call feature of the system is so to speak a bravery check this is because calling someone you do not know to have a chat with requires a certain amount of courage and most of the participants did not know each other previously to the trial in this context one of the objectives was to see whether people called more their friends and family than the other participants and whether the duration of calls with former group was longer than with the latter another objective was to see how this behaviour changed through time and if by the end of the trial the data would have shown an increased engagement among participants as the frequency of calls decreased slightly throughout the trial their duration increased towards the end for both calls between primary participants and with friends and family this could suggest that through time people got to know each other and had less frequent but longer and more meaningful conversations with regard to messaging a significant drop was observed between the first and second half of the trial it is likely that this feature was seen as more novel to the users than the calls furthermore it provided a less intrusive from of social interaction and would have been particularly useful for initial introductions at the early stages of the trial a novelty effect was also observed for postbroadcast chats in which there was a significant decrease in use despite a consistent rate of attendance to broadcasts this means that opportunities to chat remained the same but participants deciding to seize on these became less frequent the broadcasts were designed to encourage and support the meeting of new people and so this drop would be expected once they had become acquainted broadcast type also influenced usage in particular those regarding health issues were far more likely to attract both listeners and conversation than others the remote logs provide useful descriptive insight into how the technology is used in a home setting as others have highlighted self reports alone are limited by participants wishes to praise the researcher rather than give an objective view 19 the logs data were instrumental in facilitating the interview and help elicit reasons behind decisions to use or not use the technology the data from remote logging also provided an overview of the extent to which users engaged with the new technology and how this changed over time it should be noted however that with such a small sample it is difficult to generalise the results and that participants were aware of being part of a research study and of being logged furthermore a longer trial may have revealed more significant changes in usage the nature of the trial which aimed at being as natural and unobtrusive as possible also meant that some confounding factors could not be controlled for for example some participants went away while others could not use the system due to illness furthermore a subset of the sample had additional contacts with the pc client which may have biased their use of the device despite these limitations the data provided a useful insight into how different users adopted the technology during the course of the 10 weeks trial which could not have been established through selfreports relating the log data with users background characteristics would also suggest that usage was not influenced by prior experience with the technology however gender and levels of loneliness did have some impact on system use which is discussed in the next section socialising through technology the aim of the present study was to explore how the technology was used and supported social interaction in realworld settings beyond the laboratory to this end there was little intervention or facilitation by the researchers it was made clear to participants at the beginning of the trial that they were free to use the system as much or as little as they wished the device was located in a position established by participants this likely had an impact on the interaction and usage with the device the majority of participants reported that they liked the system because it provided opportunities to meet new people and were satisfied with it as a means of communicating however it should also be acknowledged that over half of the participants provided being part of the study as one of explanation for their engagement with the system despite efforts to minimise researcher effects the duration of the trial and the awareness of being logged might have played a role in usage patterns nevertheless analysis of usage data and accounts from the participants highlight a number of issues and challenges related to the development of communication technology to support social connectivity firstly there was variability in use across participants analysis of usage logs across features indicated that engagement differed across gender and loneliness this led to the problem of frequent users becoming frustrated with the relative disengagement of others for example there were frustrations around getting no response or delayed responses to messages and missed calls i make contact send messages and people dont reply the impact of fellow users on an individuals overall experience highlights the point that the users themselves constitute the system not the technology alone second the system produced some expectations related to the social norms connected with usage one of such norms for example regarded the tea room the feature that obtained the most polarised feedback at the beginning of the trial one of the participants stayed in the tea room without leaving it for long periods of time while doing other things in the house that meant that even if her avatar was in the tea room she was not anywhere near the device and that other participants joining in were left under the impression that someone was there even if there was nobody at the keyboard this person was told about it by some participants felt guilty about it and reported that she would be careful to avoid doing so again third the participants highlighted a need for greater flexibility over privacy and personal identity during the usercentred design research done to develop the prototype it emerged that some people had concerns around security when interacting with strangers via communication technology this included worries about sharing personal details as well as physical identity consequently contacts were represented using a generic avatar and first names however during this study as the trial progressed and users became familiar with each other participants expressed desire to have access to some record of information about different people as well as the ability to see each other via a webcam during calls more work is needed to see how information can be shared in a graduated way to maintain sense of privacy without hindering social relatedness as people get to know each other fourth one of the major factors of engagement with technology is perceived relevance the broadcasts on health were by far the most popular and highly attended than any other type of broadcast this suggests that informative or educational content which is perceived as beneficial in itself acts as an effective channel for encouraging social interaction this aligns well with the findings of a systematic survey of loneliness intervention studies carried out between 1970 and 2002 nine out of the ten most effective interventions in this survey involved group activities with educational or support input participants in the trial suggested that they also enjoyed broadcasts with geographically local information content news and history 20 finally there was consensus among participants that the system would work best in conjunction with meeting up face to face through the trial primary participants did set up meetings with other participants with whom they found things in common and scheduled events that people could attend furthermore at the end of the trial people expressed desire to meet with other participants and to see their faces they also suggested that an inperson meeting before the actual deployment would have helped connectedness among participants one participant said i think there comes a point where you do actually need to meet to become really friendly with somebody its a sight barrier not being able to see their faces i cant quite say why while another suggested that for the trial to be more successful in engaging participants in socialising it would have been nice if we were met and went walking or to a pub this leads to believe that a technology of this kind would probably work better in conjunction with facilitating some personal facetoface interactions the benefits of using the technology for communicating would be amplified if supplemented with occasional facetoface contact conclusion this paper describes a 10 week home trial with a novel communication system designed to encourage social engagement among older adults who do not know each other in an opportunistic and unobtrusive way the technology used in the present study emerged through a participatory design process involving older adults to ensure that the design was grounded in an understanding both of user needs and practices 1521 this home trial was an exploratory study to see how the system was used in the context of real homes outside the laboratory and how it could be improved to encourage social engagement the quantitative and qualitative data provided insight into how the system is used in a home context and provided further support in understanding participants perceptions of the system and how it could be effectively implemented despite being a completely new system participants generally found it easy to use they reported that it helped social connection and created interactions outside the system as one participant commented it made me feel as though there was somebody there for me and i was there for somebody the challenge for such as a system is to maintain social engagement findings from the trial suggest that quality of social engagement over time is limited in the absence of a graduated approach to sharing personal information as users become familiar with one another and even open up to the possibility of meeting facetoface the efficacy of the technology would also be enhanced if supplemented with the group meeting before the technology is deployed the broadcast feature was core to the design as it aimed to provide an opportunity to meet and a topic for conversation it was observed that this was most successful when the broadcasts included informative or educational content around health as opposed to less instrumental themes such as comedy news or stories this suggests the need to take a dual benefit approach in which opportunities for social interaction coexist with an opportunity to learn this study also demonstrates the importance of using both qualitative and quantitative approaches to exploring how technology is used in real contexts to inform the design process and understand how it should be implemented to successfully encourage social engagement future directions for this research could explore the novelty effect curve and engagement over time during longer trials also intervention studies could be conducted in which loneliness assessments are repeated before and after the deployment to assess potential improvement in people quality of life finally engaging with larger numbers of primary and secondary participants would provide statistical power for generalisation to a broader social context

this article explores mixed methods data gathered from a pilot of a communication system prototype in the homes of 19 older adults over a period of 10 weeks the system has been designed to enhance communication among both friends and strangers and has been developed as a possible tool to increase interaction in older adults suffering from social isolation and loneliness the paper uses remote logging data to inform discussion of how such a technology was received and utilised over time in a home setting qualitative data gathered via entry and exit interviews and weekly checkpoint calls were used to provide deeper insight into patterns and practices identified via the logs

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introduction the specialities of special care dentistry and dental public health share a set of common professional and ethical values including concerns over fairness dignity autonomy inclusion and social justice special care dentists their wider clinical teams and health and social care partners principally focus on the clinical aspects of providing high quality and appropriate clinical care to adult patients with special care dental needs in contrast those working in dental public health focus on the population level acting as advocates for policy change to promote oral health in their communities and service developments to improve access and quality of dental care both these specialities however share a common concern for vulnerable groups in society and the need to tackle oral health inequalities in the uk for the purposes of the speciality individuals and groups who may require scd are described as having a physical sensory intellectual mental medical emotional or social impairment or disability or more often a combination of a number of these factors 1 the term vulnerable adults therefore includes people living with disabilities as well as marginalised and excluded groups this paper will explore the meaning of oral health inequalities and present a unifying theoretical framework that highlights the shared causes and influences on vulnerable adult population groups examples of epidemiological evidence for the burden of oral diseases on vulnerable adult populations will be presented and recommendations made on action needed to improve access and quality of primary dental care and strategies to reduce oral health inequalities across vulnerable adult populations although the paper has primarily a uk focus the issues raised also have a wider international relevance defining oral health inequalities oral diseases are not evenly distributed across the population instead dental caries periodontal disease oral cancers and other conditions of the mouth and teeth disproportionally affect the most vulnerable and socially disadvantaged individuals and groups in society 234 these differences in oral health status across groups in society do not occur by chance and are not inevitable oral diseases are caused by a complex array of interacting factors many of which are largely beyond individuals direct control 5 oral diseases are preventable to a large extent and therefore are avoidable it is simply unfair unjust and unacceptable that the most vulnerable and disadvantaged in society suffer the most from oral diseases 67 the unequal distribution and burden of oral diseases therefore provide a perfect example of health inequality 8 oral health inequalities are often framed and viewed from different perspectives many public health researchers particularly focus on socioeconomic inequalities in oral health a very extensive international literature has shown the direct linear association between different measures of socioeconomic status and the prevalence and severity of oral diseases in children young people adults and older people 91011 socioeconomic inequalities in oral health are not merely differences in oral health status between the rich and the poor as is the case with general health a consistent stepwise relationship exists across the entire social spectrum with oral health being worse at each point as one descends the social hierarchy 12 this universal phenomenon known as the social gradient is found at all points across the life course from preschool to older age in different clinical and subjective outcomes and across different populations and settings across the world 1314 inequalities in oral health also exist across different ethnic minority groups however this is a complex topic and it is incorrect to assume that all minority ethnic groups have poorer oral health status than the majority white population 15 in some countries such as the usa australia canada and new zealand indigenous first nation populations have very poor oral health compared to the majority population 16 refugees and migrants forced to leave their home countries because of war discrimination or natural disasters also often have high levels of oral health need 17 from a clinical special care dentistry perspective oral health inequalities are often viewed more specifically in relation to disability and complexity of clinical need 18 given the difficulties in describing the scope and need for scd this largely biomedical perspective has been broadened to consider need in terms of a disability or activity restriction that directly or indirectly affects oral health within the personal and environmental context of the individual 19 and also includes consideration of the wider influence of social vulnerability and disadvantage on oral health 20 box 1 presents a list of vulnerable population groups that may experience oral health inequalities in disease status andor access to dental services overview of epidemiological evidence on oral health inequalities among vulnerable adult populations one in five people in the uk live with a disability accounting for 21 of the population in 201718 21 the prevalence of disability increases with age with 18 of working adults and 44 of state pension adults reporting a disability according to the world health organisation worldwide people with disabilities experience poorer health outcomes lower levels of educational attainment are less likely to be in employment and more likely to live in poverty compared to the general population 22 furthermore they are more likely to be dependent isolated and to have restricted participation in society 22 international evidence shows that vulnerable populations have an increased risk of poor oral health compared to the general population yet often have worse access to the care they need this is true across a broad range of people experiencing disability for example people living with an intellectual disability have been shown to have poorer oral hygiene higher prevalence and more severe forms of periodontal disease and have similar caries rates compared to the general population 23 several studies have also shown that people with id were less likely to have received dental treatment and when they did they were more likely to have had teeth extracted rather than restored 2324 this was particularly the case for people with id resident in institutional settings or who were unable to tolerate and cooperate with dental treatment 2324 similarly people with severe mental illness have been shown to have significantly higher levels of tooth decay and are more likely to become edentulous when compared to the general population 25 a systematic review looking at the association between oral health and substance abuse found that individuals with substance use disorders have greater and more severe dental decay and periodontal disease than the general population 26 people facing homelessness also experience very poor oral health compared to the general population homeless individuals have higher levels of untreated decay and periodontal disease and poorer oral healthrelated quality of life outcomes in addition the prevalence of dental pain among homeless people is common 2728 studies on prisoners suggest they experience more decayed fewer sound fewer filled teeth and worse periodontal conditions than the general population 293031 likewise refugee and asylum seeker populations experience greater burden of oral diseases even when compared to the least advantaged groups in society 17 finally research on people with dementia suggests that oral health outcomes are considerably worse compared to those in the agematched general population moreover there appears to be an association between the extent and severity of their oral health conditions and the level of cognitive decline 3233 little is known about the oral health of other vulnerable groups such as travellers and sex workers as research is sparse however the limited findings indicate that they experience disproportionate amount of dental disease and poor oral health 343536 figure 1 presents the cliffedge in oral health experienced by people living with longterm disability homeless people and prisoners when compared to the general adult population in england wales and northern ireland 272937 even compared to the lowest occupation and poorest groups people living with disability homeless people and prisoners all had much higher levels of untreated decay furthermore evidence suggests that there are a number of barriers to the provision of oral care for people from vulnerable population groups these include patientcentred barriers and professional service barriers 38 anxiety and communicationrelated issues have been shown to be significant barriers to the utilisation of dental services in particular to people with intellectual disability 39 people with mobility impairments often face challenges when accessing care as well 40 oral health care professionals attitudes lack of training and financial considerations have also been cited as limiting access to dental services 4142 unifying theoretical framework action to improve access to dental services and policies to tackle oral health inequalities both need to be informed and guided by a theoretical framework 43 health policy aiming to reduce health inequalities has been heavily influenced by the seminal who review which presented a theoretical framework to aid understanding of the underlying political economic and societal causes of socioeconomic inequalities in health the socalled social determinants 44 the who framework has been adapted and modified to also consider the broader causes of oral health inequalities across the general population 45 the who international classification of functioning disability and health has classified disability into three dimensions body function individual activity and participation in society 46 these dimensions are influenced by the broader environmental context 47 and the icf framework has also been applied to oral health 19 however as far as the authors are aware to date no theoretical framework has been developed to encompass and combine the social determinants of health inequalities and more specific factors influencing and determining the oral health of vulnerable and marginalised groups in society 48 we have therefore further adapted the existing oral health inequalities framework to include more specific factors that may have greater influence on the oral health of vulnerable and marginalised groups in society the essence of the theoretical framework is to highlight the overriding influence of the structural determinants of health the upstream socioeconomic political and societal drivers of health these factors create and determine the social and physical conditions of life as well as the opportunities and choices available or not so to people for example macroeconomic and monetary policy determines economic growth income levels and distribution of wealth in society social welfare and education policies influence training employment and support services available across society and how these services are delivered in turn the intermediate determinants include individuals social position and the circumstances in which people live their daily lives social position includes traditional measures such as social class income level and educational status however it also includes a persons perceived social standing in society the respect they are given by society circumstances includes both material conditions of daily life for example quality of housing and social relationships such as the quality and nature of personal and family relationships psychosocial factors include a wide range of influences such as selfesteem and stress and lastly but very importantly access to appropriate health services is another intermediate determinant of oral health the proximal determinants or downstream factors highlight the importance of healthrelated behaviours such as diet alcohol tobacco and hygiene and the biological factors that are directly involved in disease processes such as inflammation infection and immune responses the value of this framework is to highlight the range of interlocking distal and proximal factors that interact to ultimately influence and determine the oral health status of individuals and populations across society it is important however to also consider the more specific factors that determine the oral health status of vulnerable adult groups in society figure 2 therefore includes positive enabling factors that promote good oral health and the negative disabling factors that drive oral diseases in this population the enabling processes include living in supportive environments particularly in early life and childhood through a supportive stimulating and stable family environment also education training and work environments need to be supportive and inclusive to those with different abilities 38 opportunities and choices should be available throughout life a socially inclusive society in which respect autonomy encouragement and support is available to all empowering and building resilience and selfrespect is vital high quality health social and welfare services need to be available accessible appropriate and welcoming to vulnerable adults 49 in contrast the disabling processes and mechanisms include experiencing a difficult and traumatic early life when adverse childhood events can cause longterm emotional social and physical harm growing up in poverty combined with other forms of disadvantage cluster together to create conditions that marginalise and exclude people from society and limit their opportunities and choices in life institutional and personal discrimination and stigma experiences of abuse harassment and violence all combine to reduce a persons selfesteem and selfworth and compounds their sense of vulnerability and exclusion action to improve access and quality of dental care for vulnerable adults dental care professionals have an ethical and professional responsibility to care for vulnerable patients indeed from a legal perspective in the uk it is unlawful to discriminate against a patient who is classified as being from a protected status group 50 it is therefore vitally important to consider how best dental services can respond and meet the diverse needs of vulnerable and disadvantaged population groups this is everybodys business and a shared professional responsibility despite the evidence of higher levels of need many patients from these vulnerable groups will have routine dental treatment needs that can be best met by mainstream primary dental care services 38 general dental practitioners and their teams therefore have a key role to play in providing highquality and appropriate care to patients from vulnerable population groups as is the case with the mainstream population patients from vulnerable population groups should have their preferences choices and autonomy fully respected with regards to their dental care needs this therefore requires all dental practitioners to offer care to vulnerable patients in their local areas rather than this being offered only by a limited number of specialised services dental teams however need to have the appropriate skills and in certain circumstances equipment to be able to offer dental care to vulnerable groups ongoing training and support for dental practices is therefore essential 38 across local areas regular oral health needs assessments should be conducted which may provide information on the oral health needs of vulnerable population groups this information may provide useful data on the details of vulnerable groups in the locality and their oral health needs to ensure that dental services can respond appropriately and establish ongoing continuity of care in addition to providing necessary treatment it is essential that appropriate monitoring and evidencebased prevention is also offered to reduce future disease risk this opens up an important role for members of the wider dental team who can deliver clinical prevention as part of their ongoing quality assurance activities dental practices could include access and equity audits to assess how well their practices are performing in relation to meeting the needs of patients from vulnerable groups these audits can review and assess all aspects of dental practice policy and procedures to determine how accessible accommodating welcoming and effective they are for vulnerable patients information gathered from these audits can provide valuable insights to inform training and development needs for staff and the further development and refinement of practice policies and procedures in certain cases patients from vulnerable groups may have more complex care needs that cannot be met by a general dental practice team in these circumstances clinicians with more advanced skills and competencies level 2 and 3 as defined by nhs england 51 will need to provide more specialised care and support managed care pathways and clinical networks are part of the necessary infrastructure to enable primary care teams to refer more complex cases to specialised colleagues in community or hospital settings to be effective these developments need professional cooperation communication and management commitment and support improved liaison and cooperation is also needed between dental care providers and medical and other health and care professionals involved in supporting vulnerable patients box 2 key issues in dental service delivery for vulnerable adult groups 5253 in other areas of public health such as tobacco control and obesity prevention it has been shown that the most effective way to achieve significant population health improvement is through the implementation of a range of complementary policies that together create a healthier environment 5 the same principles apply to the necessary action needed to tackle the oral disease burden in vulnerable and disadvantaged populations upstream healthy public policies to reduce sugar tobacco and alcohol consumption would all have a particular benefit to the most vulnerable in society pricing policies on alcohol tighter regulation of advertising and promotion of sugary foods and drinks and further restrictions on smoking are examples of actions that would benefit oral health and indeed general health too 48 to achieve changes in legislation and regulations requires coordinated strategic partnerships as well as effective advocacy and lobbying of politicians and policymakers 54 dental professional organisations are increasingly becoming more active and engaged in collaborative efforts to tackle the root causes of oral and associated diseases the most vulnerable in society face the greatest barriers to achieve good health upstream public health policies can help to create a more supportive environment where the healthier choices are easier influencing national policy agendas may seem rather far removed from the work of many busy clinicians however action at a local level where dental professionals are respected members of the community can also achieve significant impact in modern society a significant proportion of our daily lives are spent in different organisational and institutional settings such as schools colleges workplaces hospitals and care homes these settings have a major influence on the health and wellbeing of the people interacting with such institutions developing and implementing oral health policies in these local settings provides an ideal opportunity to target support to the most vulnerable groups in society 55 care and nursing homes adult training centres community centres hospitals and prisons are all settings which heavily influence the oral health of people using these services unfortunately many of these settings are not always the most conducive places for good oral health policies that promote healthy and affordable food and drink choices and ensure the availability of fluoride toothpastes and toothbrushes are essential 55 fluoride varnish programmes may also be required where caries risk is very high ongoing training and support for carers and staff is also an important element to achieve sustainable improvements in oral health linking local dental practices to these settings is also essential to ensure appropriate access to care finally it is essential to recognise that oral health is everybodys business and should therefore be fully integrated into health and social care policy using a common risk factor approach 56 every clinical and social care contact should count the undergraduate postgraduate and continuing professional development of all health and social care professionals should include oral health where appropriate conclusion the burden of oral diseases disproportionally affects vulnerable and disadvantaged groups in society compared to the mainstream population to tackle these unjust unfair and avoidable inequalities in oral health requires coordinated strategic action at both clinical and population levels collectively the dental profession has a responsibility to provide appropriate high quality clinical care and to be advocates for supportive policies to protect and promote good oral health among vulnerable groups in society

highlights the evidence of oral health inequalities that exists among vulnerable adult populations and presents a theoretical framework of the underlying causes of these inequalities suggests a range of measures can be undertaken to improve access and the quality of dental care for vulnerable groups argues upstream policies are also needed to address the broader determinants of oral health inequalities